Risk Of HIV Infection In Heterosexual U.S. Men Reduced By Circumcision

A new U.S. study has found that being circumcised significantly reduced the risk of HIV infection in heterosexual African American men known to have been exposed to the virus. The findings complement those of recently reported clinical trials in Africa, where interventional use of adult male circumcision similarly reduced the risk of HIV infection in heterosexual men. The findings of the new study, along with similar results from other studies, suggest that circumcision may protect other heterosexual males in the U.S. The promising new findings are reported in the January 1 issue of The Journal of Infectious Diseases, now available online.

Lee Warner, PhD, MPH, and colleagues at the Centers for Disease Control and Prevention (CDC) and the Johns Hopkins University School of Medicine studied the records of more than 26,000 African American men who had had HIV testing during visits to two Baltimore, Maryland, STD clinics from 1993 to 2000. The subjects selected for the study said that they did not inject drugs and had sex only with women. Their visits to the clinics were classified as involving known HIV exposure if there had been a recent notification of such exposure by a sex partner or by a clinic's disease intervention specialists; clinic visits for other reasons were classified as involving unknown HIV exposure. By these criteria, the investigators found 394 visits with known exposure and 40,177 visits with unknown exposure.

In visits by men with known HIV exposure, being circumcised was associated with a 51 percent reduction in HIV prevalence (10.2 percent of circumcised men vs. 22.0 percent of uncircumcised men). In contrast, HIV prevalence did not significantly differ in circumcised compared to uncircumcised men with unknown HIV exposure (2.5 percent vs 3.3 percent).

The investigators noted that three other U.S.-based studies had previously suggested that circumcision may be associated with reduced HIV risk, but the findings were limited by small sample size or extremely low HIV prevalence and did not achieve statistical significance. Indeed, HIV prevalence in the United States is very low (about 0.4 percent), and the proportion of circumcised adult males is high (about 80 percent), which could make it hard for conventional observational studies (i.e., studies that are not clinical trials) to discern whether circumcision actually has a protective effect. By focusing on patients who had documented exposure to an HIV-infected female partner, the current study was able to reveal that there was indeed a protective effect. This approach, the investigators said, "represents a significant methodological advancement over most previous observational studies."

In a separate editorial on the topic, Ronald H. Gray, MBBS, MSc, of Johns Hopkins University, pointed out that circumcision may be especially important for minority U.S. populations, including Hispanic as well as African American men - subgroups most at risk for HIV infection. He also noted that the American Academy of Pediatrics has thus far not recommended routine neonatal circumcision, and that Medicaid does not cover the procedure. "It is to be hoped," he said, "that the paper by Warner et al., in conjunction with the weight of evidence from international studies, will persuade the Academy to recognize the public health importance of this surgery for prevention of HIV in minority U.S. populations."

Fast Facts:

Recently reported clinical trials in Africa have shown that interventional use of adult male circumcision reduced the risk of HIV infection in heterosexual men.

The current U.S. study was able to show that circumcision significantly protected heterosexual African American men. It did so by focusing on subjects who had documented exposure to an HIV-infected female partner.

http://www.medicalnewstoday.com/articles/133561.php

Uganda: Circumcision for All in 200

Uganda: Circumcision for All in 2009

Hilary Bainemigisha
19 December 2008

Kampala — All boys and men in Uganda will be mobilised for free circumcision beginning next year, the assistant commissioner for national disease control, Dr. Alex Opio, has said.

Opio said Government plans to introduce free mass circumcision before the end of 2009 as one of the ways to reduce HIV spread.

He said the free circumcision would in the long run be available in Government hospitals and health centres.

But every male will be expected to make an informed consent.

"A national policy on circumcision is coming out soon and a national task force has been appointed to speed up the process, effect mass communication and train more personnel in medical male circumcision," he said.

Whereas various researches have demonstrated that circumcision reduced a man's risk of getting HIV, 75% Ugandan men are not circumcised, according to the 2006 National Sero-Survey.

Health experts hope that new approaches like circumcision would further reduce Uganda's HIV prevalence, which has stagnated at 6.5%.

Having a circumcision policy will enable Uganda to receive funding from development partners for circumcision programmes.

"PEPFAR, the Global Fund, the World Bank and many others have all indicated willingness to fund," says Sereen Thaddeus, a USAID senior reproductive health adviser, who represented development partners at a circumcision stakeholders' meeting at Imperial Royale hotel last Wednesday.

Depending on the funding, circumcision may also be accessed from subsidised private centres at the lowest possible cost. It will be performed only by medically trained personnel in order to reduce the risk of complications.

Results from three randomised trials in South Africa, Kenya and Uganda proved that medical male circumcision (MMC) reduces sexual transmission of HIV from women to men by at least 50%.

According to Dr Angela Akol of Family Health International, this means whereas 100 uncircumcised men may all get HIV from sex with infected partners, 50 of them may escape it if all the 100 men were circumcised.

Dr. David Serwadda, Director of the Makerere University School of Public Health, who led the four-year study in Uganda, says all the studies produced similar results yet they were conducted in different countries, on different populations using different techniques.

Serwadda explains that the foreskin is vulnerable to tears and ulcers that provide an entry point for HIV. The inner skin is very soft and allows HIV to easily penetrate.

When this is cut off, the tip of the penis hardens making it difficult for HIV to penetrate.

Recent evidence from the Rakai study suggests that men with multiple partners
may get
the greatest benefit from circumcision, partly because it reduced the risk of sexually transmitted infections.

The protective effect grows over time, possibly due to the hardening of the skin on the head and shaft of the penis after circumcision.

Using computer modelling, the World health organisation (WHO) estimated that implementation of mass circumcision could avert up to 5.7 million HIV infections and three million AIDS deaths worldwide by 2026.

Based on that, WHO and UNAIDS, a UN body charged with HIV matters, issued a set of recommendations last year for the use of medical male circumcision in HIV prevention efforts.

Based on WHO recommendations, some African countries like Rwanda and Kenya have developed a national circumcision policy and are implementing mass circumcision programmes.

Opio told the circumcision stakeholders' meeting that even before free circumcision becomes available, Government is encouraging Ugandans to get the cut at hospitals and health centres that have the facilities.

However, he emphasised that circumcision does not guarantee full protection from HIV and should only be considered as one part of a comprehensive package to prevent HIV.

"People must be told that even if they are circumcised, they can still contract HIV and transmit it to their partners. Therefore, circumcised men should continue to practice abstinence, have fewer sex partners and use condoms," he said.

Opio said the national task force for male circumcision has been finalised and will include officials at the national level, those from the Ministry of Health, Uganda AIDS Commission and development partners.

Others on the task force are representatives from NGOs, districts and hospitals. "We are soon giving them appointment letters. They will be answerable to the Director General for Health Services," Opio said.

On why it has taken Uganda this long to come up with a policy, Opio explained that Government opted for a cautious approach to avoid a situation where the policy is announced and the system is not ready to absorb the demand. "We have to first build capacity, consensus, acceptability, a right communication strategy and a national task force," he said.

"The task force will now develop the policy, an implementation plan and programme as well as tools for monitoring and regular evaluation," Opio says.

However, there are still many issues to consider. Currently, doctor:patient ratio is 1:22,000 and many of these are busy with the various diseases that afflict Ugandans. The task force needs to train personnel especially midwives and nurses to back up the qualified surgeons.

Stakeholders expressed concern that political support is necessary for the programme to succeed. In Kenya where circumcision has tribal ego implications, it took the Prime Minister Raila Odinga, three ministers and six MPs to announce at a rally in Kisumu that they had undergone the operation.

President Yoweri Museveni has in the past questioned the usefulness of circumcision in HIV prevention.

But Opio said the President only raised concerns about the implication of poor communication on circumcision. "We have looked at these concerns and we are going to meet him to address them."

The presidential advisor on HIV/AIDS, Dr Jesse Kagimu, said the president has always insisted on well researched and proven scientific information on preventive HIV methods. He will support any intervention that can help roll back the scourge, he said.

Dr. Freddie Ssengooba of Makerere University School of Public Health added that a good communication strategy is needed to avoid inappropriate uptake, quarks and unsafe practices.

In his presentation on MMC communication strategy, Ssengooba said priority will be on explaining its role in HIV prevention and directing people where to go for it.

http://allafrica.com/stories/200812220132.html

Male circumcision lowers cervical cancer risk: study

WASHINGTON (Reuters) – Three studies published on Wednesday add to evidence that circumcision can protect men from the deadly AIDS virus and the sexually transmitted virus that causes cervical cancer.

The reports in the Journal of Infectious Diseases are likely to add to the debate over whether men -- and newborn boys -- should be circumcised to protect their health and perhaps the health of their future sexual partners.

Dr. Bertran Auvert of the University of Versailles in France and colleagues in South Africa tested more than 1,200 men visiting a clinic in South Africa,

They found under 15 percent of the circumcised men and 22 percent of the uncircumcised men were infected with the human papilloma virus, or HPV, which is the main cause of cervical cancer and genital warts.

"This finding explains why women with circumcised partners are at a lower risk of cervical cancer than other women," they wrote in their report.

A second paper looking at U.S. men had less clear-cut results, but Carrie Nielson of Oregon Health & Science University and colleagues said they found some indication that circumcision might protect men.

The circumcised men were about half as likely to have HPV as uncircumcised men, after adjustment for other differences between the two groups.

PREVENTING AIDS

In the third report, Lee Warner of the U.S. Centers for Disease Control and Prevention and colleagues tested African-American men in Baltimore and found 10 percent of those at high risk of infection with HIV who were circumcised had the virus, compared to 22 percent of those who were not.

"Circumcision was associated with substantially reduced HIV risk in patients with known HIV exposure, suggesting that results of other studies demonstrating reduced HIV risk for circumcision among heterosexual men likely can be generalized to the U.S. context," they wrote.

Studies supporting circumcision to reduce HIV transmission had all been done in Africa and U.S. studies were less clear.
Dr. Ronald Gray of Johns Hopkins University in Baltimore and colleagues said they found the reports encouraging.

"In the United States, circumcision is less common among African American and Hispanic men, who are also the subgroups most at risk of HIV," they wrote in a commentary.

"Thus, circumcision may afford an additional means of protection from HIV in these at-risk minorities."

But they noted that the American Academy of Pediatrics does not recommend routine circumcision for newborns.

"As a consequence of this AAP decision, Medicaid does not cover circumcision costs, and this is particularly disadvantageous for poorer African American and Hispanic boys who, as adults, may face high HIV exposure risk," Gray and colleagues wrote.
"It is also noteworthy that circumcision rates have been declining in the U.S., possibly because of lack of Medicaid coverage."
Medicaid is the state-federal health insurance program for the poor and disabled.

Thirty-three million people globally are infected with AIDS, which has no cure and no vaccine. HPV is the most common sexually transmitted infection in the world, with 20 million people in the United States infected. It causes cervical cancer, which kills 300,000 women globally every year.

http://news.yahoo.com/s/nm/20081217/sc_nm/us_circumcision_infections_1

MEN LINE UP FOR CIRCUMCISION IN AFRICA

Male circumcision catches on in sub-Saharan Africa as a way to prevent HIV infection; but demand for the operation exceeds availability

By Nathan Seppa

Clinics offering discounted or free circumcision for men in sub-Saharan Africa are experiencing long lines and keen interest as word spreads that the operation provides partial protection against HIV and may offer other benefits, researchers report.

But governments in the region have been slow to embrace the measure. As a result, demand in many countries is far surpassing availability.

“Right now, it’s a school holiday here and the clinics are absolutely packed with people,” says Robert Bailey, an epidemiologist at the University of Illinois at Chicago who is working on a male circumcision project in Kisumu, Kenya. The clinics where Bailey is doing research offer circumcision to boys age 10 and up, although most clients are men ages 20 to 25.

The experience in Kisumu is being replicated sporadically across southern and East Africa, areas where large swaths of men haven’t been circumcised and where HIV has hit the continent hardest.

Despite the lack of male circumcision in these parts of Africa, there’s long been an undercurrent in favor of the procedure in these areas, says Daniel Halperin, a global health expert at the Harvard School of Public Health in Boston. In the 1990s, focus groups and surveys indicated plenty of acceptance for the operation, he says.

Around that time, researchers first documented that areas of Africa where male circumcision was widespread had fewer cases of HIV.

Now men in southern and East Africa are actively seeking out the operation. “They’re more energized,” says Ronald Gray, a physician and epidemiologist at Johns Hopkins University in Baltimore who has worked extensively in Uganda.

This cultural shift follows the release of three clinical trials in 2005 and 2007 showing that circumcision reduces a man’s risk of acquiring HIV by at least half.

Those trials led to endorsement of the surgery by the World Health Organization, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the U.S. President’s Emergency Plan for AIDS Relief — key funding sources — as a public health measure against HIV.

African media have seized upon male circumcision as a hot story in the past few years, leading many men to openly pursue circumcision where it’s not the norm. In Uganda — where Gray is doing field work and where only one-fourth of males are circumcised — a musical group called the “Circ Squad” got circumcised and made a music video about the issue.

But the newfound circumcision chic comes with a problem: Although men and adolescent boys are queuing up in droves, many medical facilities in sub-Saharan Africa aren’t up to the task. In Uganda, Gray says, most men get put on a waiting list.

In neighboring Kenya, Bailey is seeing the same thing. “There’s much more demand than we can meet,” he says.

Despite increasing demand and even new sources of funding, including the Bill & Melinda Gates Foundation, African governments have been slow to promote circumcision as a public health measure and to mobilize resources.

Without subsidization from governments or outside agencies, the costs of the operation have limited it mainly to middle- and upper-class men. Even recently, Halperin notes, a public clinic in Swaziland that gets support from outside sources was charging about $40 for a circumcision, “not an insignificant amount for many African men,” he says.

The slow response — despite strong public demand — is the result of indifference shown in past years by international funding agencies and African governments toward the benefits of male circumcision, Halperin says. “If we had an AIDS vaccine that was half as effective as circumcision, the donors would have been all over it,” he says.

“Although evidence from the trials and biological work are very clear, it’s difficult for policy makers to get their minds around the idea that we ought to use surgery to prevent a disease,” Gray says.

Laboratory studies have tendered an explanation for the protection offered by circumcision. Uncircumcised men retain soft foreskin around the head of the penis, providing an ideal region for HIV to infect. Circumcision removes this tissue, leaving only skin that’s toughened with keratin, a protein that resists viral invasion, Bailey says.

Make no mistake, circumcision is only partially protective. And some people have worried that men, once circumcised, would become careless and have more unprotected sex. But early studies of the issue show little evidence of that happening.

For men who are ambivalent about being circumcised, the new wave in Africa offers an opportunity to have a hygienic version of the operation in a clinic. For those who come from groups with traditions of circumcising boys, the clinical availability is safer than a traditional ceremony that carries risks of complications, says Neil Martinson, a public health physician at the University of the Witwatersrand in Johannesburg, South Africa.

Recent studies suggest that circumcised men are less likely to get other sexually transmitted diseases, particularly herpes and human papillomavirus, says Gray.

Halperin notes that men and women often cite sexual pleasure, perceived to be greater if the man is circumcised, as a reason for the operation.

Indeed, women seem to have plenty of say in the decision making, Bailey says. “Many women prefer men who are circumcised because of the hygiene issue,” he says. “And our clinics are packed with mothers bringing their sons in to get circumcised. “

Circumcising young male children raises a question of how to best allocate health resources, Martinson says. While it may seem to make sense in the long run to circumcise all boys, “that might divert resources to [infant] kids when there are 16- and 18-year-olds who should be getting circumcised and who have a clear, direct risk of contracting HIV,” he says.

Halperin says Swaziland, which has opened clinics on weekends just for male circumcision, and Botswana, with a government-funded promotional program, are leading the way among countries that currently have high HIV burdens and low circumcision rates. Rwanda is planning a large-scale male circumcision campaign focused on the country’s military and possibly university students. Zambia has received substantial outside funding to gear up a male circumcision program, but still has long waiting lists.

South Africa has yet to develop a policy regarding male circumcision. But in Orange Farm, just outside of Johannesburg, researchers with the French National AIDS Research Agency are circumcising and then monitoring young men in an effort to document the long-term effects on community HIV rates. Surgeon Dino Rech, who works at Orange Farm, says doctors are circumcising 20 to 100 men per day, by far the largest program in South Africa.

The results of this study and the effect of mass male circumcision in Africa won’t be known for years, says Lawrence Gostin, an attorney at Georgetown University in Washington, D.C. Meanwhile, Gostin is working with UNAIDS to develop a checklist of issues that countries can use as they put male circumcision to work as a public health measure. These issues include safety evaluations for clinics, sensitivity to privacy issues and ensuring access to poor people and those in remote areas. The outline appears in the Dec. 3 Journal of the American Medical Association.

Still up in the air is the knotty question of whether to screen men for HIV before circumcision, he says. Excluding HIV-positive men and boys could constitute discrimination, breach confidentiality and cause stigmatization, Gostin and UNAIDS’ Catherine Hankins note in the JAMA article.

Safety will be a crucial issue. Since high complication rates from surgery could derail a campaign promoting it, countries will have to make sure clinics have sterile facilities, proper instruments, trained personnel and close follow-up of patients, says Ingrid Katz, an infectious disease physician at Harvard Medical School in Boston. Katz and Alexi Wright of the Dana-Farber Cancer Institute in Boston discuss the issue in the Dec. 4 New England Journal of Medicine.

http://www.sciencenews.org/view/generic/id/39048/title/Men_line_up_for_circumcision_in_Africa

The kindest cut: How circumcision is the secret weapon in the battle against HIV/Aids

In Zambia, an experiment in the battle with HIV/Aids is producing staggering results. If this were a vaccine trial, the medical world would be hailing it as a miracle. But instead of a wonder drug, the secret weapon is circumcision. Jeremy Laurance reports

Monday, 1 December 2008

After weeks of waiting, Michael Phiri decided to take matters into his own hands. The 16-year-old from George Compound, a township outside Lusaka, was so anxious to be rid of his foreskin, and so frustrated after being turned away from the circumcision clinic at local hospital for the third time, that he took a bread knife and did the job himself. The resulting bloody mess had one positive outcome; it sent him straight to the top of the queue for surgery, and he got his operation performed, as an emergency, by the urology specialist Kasonde Bowa.

"He had made a good start, with a dorsal cut as far as the rim of the glans, but things had got difficult from there," a smiling Dr Bowa says, with admirable understatement.

***

As Zambia's leading expert on circumcision, Bowa tells this story (the patient's name has been changed) to illustrate the soaring demand for the procedure that is sweeping Lusaka and other towns across sub-Saharan Africa, as word spreads of its remarkable preventive power. After 25 years of research and the expenditure of billions of pounds, it turns out that the oldest surgical operation in the world, performed since antiquity, is the best defence we have against HIV/Aids.

In crisp shirt and tie, despite the sweltering heat, Bowa tells me of the benefits of circumcision. We're standing outside his cluttered office at the University Hospital, where the exotic flamboyant trees that pepper this sprawling city shed their vermilion blooms on to the patients waiting in the shade below.

Bowa started Zambia's first pilot project offering circumcision as a defence against HIV in 2004. It was soon overwhelmed. "We were operating three afternoons a week but had such high demand that we were unable to cope. We needed more space and more staff."

The simple act of removing a man's foreskin reduces his risk of contracting HIV by about 60 per cent. The reason is that the moist underside of the foreskin is thickly supplied with Langerhans cells, a key route for entry of the virus into the body. Langerhans cells are also present in the glans (head) of the penis, but after circumcision the skin of the glans becomes drier and thicker, denying the virus an easy point of entry.

The medical evidence, from a series of studies, of the protective effect of circumcision has been growing for two decades, but it is only since publication of three randomised trials in Kenya, Rwanda and South Africa in late 2006 that the global health community started to act. The trials were stopped early and all 10,000 men involved offered circumcision when initial findings showed that the protective effect was so great that it would have been unethical to continue.

In March 2007, the World Health Organisation and UNAids gave their official backing to circumcision and called on countries to offer it to all heterosexual men. Kevin de Cock, head of the WHO's Aids department, described it as "an extraordinary development", adding: "Circumcision is the most potent intervention in HIV prevention that has been described."

In the story of Aids, it is rare to come across a development as positive as this. Tragedy has been piled upon tragedy, and the world has tired of the unremitting gloom. Flooding Africa with condoms and trying to change sexual behaviour has had little demonstrable impact. Research on an Aids vaccine has foundered and an effective microbicide is still not in sight.

The toll from the disease is staggering – an estimated 33 million people infected with HIV, and 25 million dead. Even more alarming, however, is that new infections are growing by 2.7 million a year, outnumbering the annual two million deaths. For every two people put on drug treatment, five more become infected.

Against this litany of despair there is now, for once, a message of hope – a chance of curbing, and even reversing, the epidemic. Circumcision, if rolled out across the continent, offers the first real prospect of saving lives by preventing infection on a significant scale. Estimates suggest that if universal circumcision were introduced across sub-Saharan Africa, it could prevent 300,000 deaths in the next 10 years and three million deaths over the next 20 years. It is sometimes described as a "surgical vaccine" – with good reason.

Zambia has been among the first to offer the operation and pilot new services, and other countries are following its lead. Yet, globally, only 1 per cent of total Aids funding is earmarked for male circumcision. Progress towards delivering the single most effective preventive measure yet discovered against the pandemic is agonisingly slow.

Across the road from Bowa's office, what is believed to be the world's first dedicated circumcision clinic outside a hospital or research programme is doing brisk business. Launched last year by the international charity the Society for Family Health, following Bowa's lead, the New Start centre is sited in an anonymous, dusty building behind the YWCA. Its appearance gives no hint of the pioneering work carried out within. This is deliberate; the charity fears that the service would be besieged if it were more widely advertised.

As I watch, John Banda, a shopkeeper, aged 29, climbs on to the table in one of the three operating rooms, clutching his green surgical gown and grimacing at the ceiling as Aggie Mahule, one of half a dozen nurses and clinical officers given two weeks' training to carry out the procedure, injects local anaesthetic into the base of his penis. "Relax and feel at home," says Aggie kindly as she swabs the surgical area with disinfecting iodine. John, fearful of the pain and, possibly, for his manhood, makes no response.

Next door in the "recovery" room, Richard Chimuka, 31, a computer trainee wearing a black designer shirt and low-slung jeans, sits with his legs apart, looking relaxed and pleased that, for him, the operation is over. The surgery was over in 12 minutes – and no, it wasn't painful, he says. Does it bother him that the operation was performed by two women? "Actually, I felt excited about it – like putting my painting in a gallery," came the smooth reply.

***

It's not difficult to persuade Zambians of the virtues of circumcision. It is already practised traditionally by the Luvale and certain other tribes in the North-Western Province, where the HIV rate is half that in the rest of the country (6.9 per cent of the population in the region is infected, compared with 14.3 per cent for the country as a whole). In Lusaka, one in five of the adult population is infected (20.8 per cent), one of the highest rates in the world. Surveys have shown wide acceptance of the procedure and increasing interest among parents wanting the operation for their children.

More than 1,500 men have had the operation since the New Start clinic opened in August 2007, and more have been circumcised by mobile surgical teams that visit hospitals in Kafue and Kabulonga, an hour's drive from the city. This is good for them, but in the context of the country's epidemic – 100,000 new infections a year – it is like using a water pistol against a forest fire.

In a week spent in Lusaka, I searched for any agency, charity or expert opposed to rolling out circumcision – and I could not find one. Among the dozen organisations I visit, all voice their support – only the level of enthusiasm varied.

"It is the most important defence against the disease that we have," says Mannasseh Phiri, a GP and Zambia's best-known Aids activist. "The trials have shown that it really does work, it is relatively easy to do and it is a lot cheaper than putting people on drug treatment."

Jeffrey Stringer, director of the Centre for Infectious Diseases Research in Lusaka, which is piloting a neo-natal circumcision service, tells me: "If we had a vaccine as effective as this, we would be jumping up and down in the streets. A 60 per cent protective effect is fantastic. It is one of the most effective preventive strategies we have." Yet, as Steve Gesuale, head of the circumcision project at the Society for Family Health, points out, there is "very little funding from donors, very little government support and very little going on".

Why? Official backing from WHO and UNAids has not been enough to persuade governments and donors to put their money and resources behind circumcision – yet. Richard Harrison, the director of the Society of Family Health, says the reason is fear. "There is always a sense of jeopardy around big decisions, especially when they involve sex. You only have to remember the row over condoms 20 years ago. By endorsing circumcision publicly, the Zambian government would be exposing itself to criticism, especially from religious groups who are incredibly powerful. The government is not going to shout its support from the podium – it prefers to give it tacitly."

There is also the difficulty that an HIV/Aids prevention strategy is all about the future, because it takes at least a decade for the benefits to be felt, while treatment is about the here and now. "It is very difficult to get people to concentrate on something that is 10 years away," he says.

Neighbouring governments, members of the Southern African Development Community, have been unable to agree a common approach. President Yoweri Museveni of Uganda dismissed the proposal as the West's latest "golden calf" which Africa was expected to worship and warned that it could suck resources from other preventive strategies (a concern shared by some of the charities I spoke to).

In Malawi, a former minister of health is reported to have said that she would not back any measure that benefited men and not women. (Women would, of course, benefit indirectly if fewer men were infected – and estimates suggest that male circumcision would save more female lives than any other preventive method.) The Malawian ex-minister's response may have been a cover for the real reason – a fear that the proposal was an attempt to Islamise the country.

While Kenya and Rwanda have announced policies favouring circumcision, they have yet to find the resources to put them into practice. Only Botswana, smaller and wealthier than Zambia and with one-tenth of its population, has forged ahead, offering the operation in all government hospitals after President Festus Mogae enthusiastically declared: "We have nothing to lose but our foreskins."

In Zambia, despite the lack of public support, the message about the benefits of the operation is reaching all levels of society. In Garden Compound, the densely crowded township close to the centre of Lusaka, the tiny Viro Clinic – "We prolong and save" reads the legend above the door – displays a poster in the window advertising male circumcision. Outside, the faded red and blue plasterwork is crumbling. Inside, the three cramped rooms contain a pot plant reaching almost to the roof, an examination couch doubling as the operating table, and a small fridge. Beside it, on a table, a teddy bear is propped against a broken clock, along with red plastic roses.

Violet, the smiling receptionist, says demand for circumcisions has increased. "There are more in the winter [June and July] and in the evenings and early mornings when it is cooler. The wound heals better," she says.

Interest in circumcision has spread beyond the capital, to the country's vast hinterland, according to Karen Sichinga, chief executive of the powerful Churches Health Association of Zambia, which runs one-third of all Zambia's hospitals, mainly in rural areas. "The demand is increasing in our mission health facilities," she says.

For Sichinga, the operation does not carry the moral dilemmas involved in handing out condoms or preaching abstinence, an important factor for a faith-based charity. But she, like some others, is cautious of treating it as the silver bullet, the "answer" to Aids that has been so desperately sought for so long.

"Science has proved that the benefits outweigh the disadvantages," she said. "But you have to work hard to persuade people. Over 90 per cent of Zambia is Christian, not Islamic."

***

From township clinics to mission hospitals in the furthest reaches of the country – all such facilities will need to be recruited if the target of 500,000 circumcisions in five years, notionally set by the Society for Family Health, is to be achieved. Even that represents only half the number required to curb Zambia's HIV infection rate, calculated on the basis that four operations are needed to prevent one infection.

Supporters of the programme are pinning their hopes on a substantial chunk of the $307m (£200m) allocated to Zambia by the Global Fund last month being used for a major scale-up of circumcision. The Gates Foundation is also considering a proposal which, if approved, would provide millions of dollars for the strategy.

Some experts, including Bowa, warn that even if the money is available, the vast increase in staff and facilities needed will take time to deliver. Others are more optimistic. Hospitals are already being used at weekends, with existing staff paid extra, and discussions are under way to hold circumcision clinics in the evenings. High-risk groups could be targeted first – the military, the police. It is not as simple as rolling out a vaccination programme, but there is already experience with cataract surgery, which is provided to hundreds of thousands of people across the world by staff with basic training, and circumcision providers from several countries in Africa have travelled to India to learn from the cataract experience.

Catherine Sozi, country co-ordinator for UNAids, dismisses suggestions that extending circumcision right across Zambia would prove too great a challenge. "That was what they said about anti-retroviral drugs – that they could not be provided in poor areas that lacked medical support. It will never happen, they said – and look how well we have done. We will scale up circumcision. The studies show it is working. It will become a human rights issue if we don't."

Science and society: Why circumcision works 

Circumcision is an essential weapon in the fight against HIV/Aids in sub-Saharan Africa because, uniquely in the world, the disease there is widespread in the heterosexual community. 

Although it offers less protection (60 per cent) against the virus than a correctly used condom (100 per cent), condoms are only effective where the key risk-groups are sex workers and their clients, and men who have sex with men. 

In sub-Saharan Africa, the main driver of the epidemic is multiple concurrent relationships – the practice of taking several lovers at the same time. Condoms are not the answer in this context because these are long-term relationships, including marriage, in which condom use is low. Surveys in Zambia show that only 30 per cent of men use condoms, mostly in casual sexual encounters. Circumcision confers protection, though limited, in all situations, for life. 

Critics fear that circumcision will encourage men to think they are immune and to ignore safe-sex advice, so increasing risks. Evidence from the trials in Kenya, Rwanda and South Africa showed no change in sexual behaviour following circumcision – and at the Society for Family Health's New Start clinic in Lusaka, men are repeatedly warned each time they return for a check-up that they are not completely protected and need to continue practising safe sex. 

There are also fears that men will not wait for the wound to heal – six weeks is the recommended period of total abstinence, from intercourse and masturbation. Sex during this period could be dangerous as the wound is an the ideal pathway for HIV transmission. Men are warned of the dangers and there is no sign they are returning to sex too early.

A third objection is that the operation benefits men but not women. This has angered groups concerned about equal rights. But a reduction of HIV prevalence among men will indirectly benefit women. Estimates suggest that male circumcision has the potential to save more women's lives than any other preventive measure. 

At the Society for Family Health's clinic, men are offered an HIV test before the operation, and more than 80 per cent accept the offer. Calls for the test to be made mandatory have been rejected because of concern that it could deter people from seeking the surgery. 

Some experts warn that circumcision must only be offered with counselling and HIV testing. Others say quantity is what counts and services should be established on a factory model. At Orange Farm in South Africa, one of the three research sites whose work led to the WHO announcement, a conveyor belt service is offered, with a target to circumcise 80 per cent of the men among the town's 200,000 population. A study of the cost-effectiveness of the operation suggested that, if scaled up to 25,000 procedures a month at $47 (£31) each, it could save more than $60m in treatment costs over eight years. 

Rolling out the surgery may be less easy in some countries. In Zambia, efforts to scale up circumcision have the support of traditional circumcisers and there are no cultural objections to the practice. In Kenya, however, circumcision is a mark of tribal identity; non-circumcising tribes such as the Luo are resistant to adopting a practice associated with their rivals. Top politicians from the Luo community, including three government ministers, have recently admitted to being circumcised in an attempt to promote the culturally taboo practice.

Read online

'Make circumcision part of preventing HIV'

The time has come for urgent action to make male circumcision part of the arsenal against HIV transmission, say some of South Africa's leading experts on the disease.

In an article in the latest issue of the journal Future HIV Therapy, they have rejected claims that calls for circumcision as a prevention strategy are based on incomplete evidence, and premature.

"As more and more people in sub-Saharan Africa become needlessly infected with HIV, the time has come for urgent and decisive leadership, not circular and unscientific arguments about an intervention whose efficacy has been proven beyond a reasonable doubt," they said.

They drew a parallel between the circumcision debate and other so-called controversial topics, such as the link between cigarette smoking and lung cancer, and between carbon emissions and climate change.

"It is time to move beyond debating the merits of this evidence in professional journals and other legitimate communication outlets and to start implementing effective programs for safe, voluntary male circumcision and reproductive health in high HIV-prevalence regions," they said.

Male circumcision was a one-off, effective procedure that was unusually culturally acceptable and sought after in many parts of Africa.

It also provided a rare and important opportunity to access a hard-to-reach population - sexually active men at high risk of HIV exposure - with a potentially life-saving intervention combined with behaviour change messages.

The authors of the article include Olive Shisana, Quarraisha Karim, Mark Heywood, Helen Rees and Francois Venter.

Their co-authors are 43 other local and international HIV and Aids experts.

In a statement issued on Wednesday, welcoming the article, the Treatment Action Campaign (TAC) said voluntary male medical circumcision (VMMC) reduced the risk of heterosexual men contracting HIV.

It was highly likely that its widespread introduction in countries with generalised heterosexual epidemics would reduce HIV incidence substantially.

VMMC was however not a magic bullet, and should be part of a comprehensive set of prevention interventions.

TAC said the SA National Aids Council should finalise a national policy on VMMC before the end of the year. - Sapa

http://www.iol.co.za/index.php?set_id=1&click_id=125&art_id=nw20081001141712287C259595

Mad rush to be circumcised

Published on 28/09/2008

By Standard on Sunday
http://www.eastandard.net/InsidePage.php?id=1143995806&cid=4

Extract:

Days after Prime Minister Odinga rallied community leaders to advocate for male circumcision, hospitals are struggling to cope with the large number of people seeking the service.

The largest turn out has been witnessed at the Migosi Health Centre where the exercise was being conducted free of charge by volunteer doctors.

On Tuesday, a day after Raila launched the campaign, prospective patients flocked health centre seeking the services.

Raila, who has fanatical following among the Luo told men to go for the cut following research findings that the circumcised are at a lower risk of contracting HIV.

"We did not anticipate it. Raila’s entry into the campaign has given it a political dimension with many people rushing to be cut just because he has said it," said a nurse at the Nyanza Provincial Hospital.

From newborns to the youth, the middle-aged and wazees are queuing to face the knife.

Surgeons at the Migosi clinic were clearly overwhelmed and had to defer 27 men. Forty-six had turned up for the cut.

"Surgery is a brittle issue. We cannot hurry the process, we have to be slow but sure and handle patients with a lot of care," said a surgeon Michael Oyaa.

The process takes about 20-30 minutes, the surgeon said. It costs Sh2,000 in private clinics. Many are turning up at Government hospitals where the service is free.

A counsellor at Migosi, John okeyo, said they had booked fresh dates for those deferred.

"Many people have heeded the call, and the turn out is overwhelming," said Okeyo.

But were they queuing for the cut because they were convinced it was the right thing to do or because Raila had said it?

Many of those interviewed said they wanted to be cut to minimise risk of HIV infection.

Kennedy Oduor, 20, said: "I want to be circumcised as I have been told it can prevent syphilis and also reduce my risk to get HIV."

He added: "I am not getting circumcised because Raila has said. His campaign is only a motivation to me and an assurance that I am doing the right thing."

Charles Otieno, 39, said he had planned to get the cut long before the Tom Mboya conference where leaders endorsed circumcision.

"You see this thing is voluntary. No one is under any obligation to go for it. You also do not need to tell people whether you have been cut or not. It is your secret," said Otieno.

Faster services

The youth are counselled and advised to undergo voluntary HIV test and counselling at VCTs set at the circumcision centres.

The officer-in-charge of Migosi VCT Ben Abuto said some of those seeking circumcision did not want to be tested for HIV.

By last Wednesday evening, about 30 per cent of those registered for the cut had been tested.

"Many of these people just want the cut and nothing else. They say they do not want to know their status," said the officer.

There has also been a massive turnout at the Lumumba Health Centre, where the research on the link between HIV and circumcision was conducted.

The centre, run jointly by the Kisumu Municipal Council and the Universities of Nairobi, Illinois and Manitoba (Unim), has superior facilities and is attending to the patients faster.

"Many people, especially the youth prefer Lumumba because it has superior facilities and more doctors," said Daniel Ouma, a form three student, after leaving the theatre.

Long Queues

The activity was slowly picking up at various district hospitals and health centres across the province.

At the Nyanza Provincial and Kisumu District hospitals, the queues were not as long as those at Lumumba and Migosi.

At the district hospitals doctors said the oldest patient they had handled was 56 years old while the youngest was a four-month-old.

Israelis help curb spread of AIDS with circumcision

As the 17th Annual International AIDS Conference was taking place in Mexico City, news has just come out that Israeli-trained doctors in the tiny African nation of Swaziland have circumcised over 800 local men this year in an effort to stem the spread of AIDS in the country, reports Dan Wooding, founder of ASSIST Ministries.

A story carried on www.israeltoday.co.il, said that representatives from the Family Life Associated in Swaziland (FLAS) told The Jerusalem Post that the procedure has been well received, and is indeed helping to decrease the spread of infection.

“Swaziland has the highest rate of AIDS infection of any country in the world, with over 26 percent of people between the ages of 15 and 49 testing positive for the disease,” said the Israel Today story.

“FLAS contacted the Jerusalem AIDS Project late last year to seek assistance in curbing the epidemic. A team of 10 Israeli doctors immediately traveled to the country and instructed local physicians on how to properly perform adult circumcisions to best reduce chances of infection.”

http://www.christiantelegraph.com/issue2618.html

Male circumcision could be even greater boon than thought

MEXICO CITY (AFP) — Circumcision appears to offer men even greater protection against the AIDS virus than thought and also partially shield them against a common sexually-transmitted disease, two studies presented at the world AIDS conference said Thursday.

US researcher Robert Bailey of the University of Illinois at Chicago put forward long-term data from a trial in Kisumu, Kenya, that in its initial phase enrolled 2,784 uncircumcised uninfected men.

Half of the group were circumcised, and the others were circumcised at a later date and they were later tested for HIV.

Previously-published research from this trial found that, after two years, circumcised men were 59-percent less likely to contract the human immunodeficiency virus (HIV) than uncircumcised counterparts.

The benefit was so astonishing that at this 24-month mark, the uncircumcised men were offered circumision, as it would have been unethical not to have done so.

In a presentation at the 17th International AIDS Conference, Bailey said the estimate of protectiveness at 24 months had been adjusted to 60 percent in the light of refined lab tests from blood specimens.

And he also reported that at the 42-month mark, circumcision offered a protectiveness of 65 percent.

This extension of the study, conducted among 1,739 of the original 2,784 volunteers, will run until December 2009.

"The 60-percent protective effect against HIV acquisition ... over the first 24 months of the study, we now find to be sustained and possibly strengthened to approximately 65 percent over three and a half years of follow-up," Bailey said.

"These results further support the addition of male circumcision to our limited armamentarium of HIV prevention."

Meanwhile, South African researcher Dirk Taljaard reported on a new aspect of a now-famous circumcision trial at Orange Farm, South Africa.

This French-led trial was the first to show that surgical removal of the foreskin offered protection against HIV, also around 60 percent.

Taljaard said that analysis of other data from the Orange Farm trial showed that circumcision offered no shield to the man against gonorrhea.

It offered only "borderline" protection against trichomonal vaginitis, a parasite that dwells in the male and female sexual organs and is transmitted through vaginal intercourse.

But it provided protection of 36 percent against the human papillomavirus (HPV), a pathogen linked to cancer of the cervix and penis, he said.

Circumcision has emerged as one of the few bright areas of progress in the AIDS crisis, after the Orange Farm and Kisumu trials.

The discovery has sparked talk in some circles of a "surgical vaccine" -- a cheap, safe method for shielding men from HIV, especially in sub-Saharan Africa, home to two-thirds of the 33 million people with HIV.

But this enthusiasm has also been tempered by worries that circumcision may face a backlash on cultural, religious or sexual grounds, or may prompt men to abandon use of the condom.

Other work at the conference, ending Friday, suggested, though, that circumcision was widely accepted by men, some of whom believed that it enhanced sexual pleasure, and did not prejudice safe-sex practices.

According to French researcher Bertran Auvert, who led the original South African study, circumcision could avert up to 3.8 million infections and half a million deaths in sub-Saharan Africa between 2006 and 2016, and up to 5.8 million deaths by 2026.

The theory behind the effectiveness of circumcision is that the inner foreskin is an easy entry point for HIV. It is rich in so-called Langerhans cells, tissue that the AIDS virus finds particularly easy to latch onto and penetrate.

Other questions surrounding a circumcision campaign are the need to ensure that operations are done hygienically and with the full knowledge and consent of the male. Also unclear is what benefit, or otherwise, male circumcision has on women.

http://afp.google.com/article/ALeqM5iSi1bgOg2ZncrTbBWPMdakIg0f4g

Mass male circumcision vital in HIV prevention

Wednesday, 6th August, 2008

By Dr. Innocent Nuwagira

Male medical circumcision is one way of HIV-prevention. Because it does not provide complete protection, it is not a stand-alone intervention but part of a package. Studies indicated that circumcised males were less likely to be infected by sexually transmitted infections, including HIV.

The most recent evidence came from trials in South Africa, Kenya and Uganda between 2005 and 2006. All the three studies established that male circumcision provided up to 60% protection against HIV transmission from women to men.

The foreskin of the penis has a very high concentration of HIV-target cells, thus making this part of the body a very weak point for HIV entry. The thin layer of the inner foreskin is susceptible to minor tears and abrasions, and can facilitate entry of infectious organisms, including HIV pathogens.

The area under the foreskin remains a warm, moist and comfortable environment for rapid replication of many pathogens, some of which cause ulcers that further facilitate HIV entry. Therefore, removal of the foreskin denies HIV this link, thus reducing its likelihood of infecting a circumcised male.

Other benefits
Apart from reducing the likelihood of HIV-infection, male circumcision also reduces the risk of genital ulcers, urinary tract infections, syphilis, chancroid, human papilloma virus, invasive penile cancer, and cervical cancer in the female partners.

Of course, all the above are in addition to improved personal and spousal hygiene.
Furthermore, there is emerging consensus that 100% coverage by male medical circumcision could avert about six million new infections and three million deaths in sub-Saharan Africa alone in the next two decades.

In Uganda, the recently concluded National Strategic Plan (NSP) puts the impact of complete coverage with male medical circumcision at a reduction of incidence by 15% in the next five years.

Global consensus
The WHO and UNAIDS have recommended that male medical circumcision be recognised as an additional important intervention to reduce the risk of heterosexually-acquired HIV-infection in men. It is emphasised that male medical circumcision be considered together with the ABC+ strategy and not a substitute of any effective prevention method.

It is further recommended that countries with high HIV-prevalence and low rates of male circumcision consider to urgently scale up access to male medical circumcision services.

These services are to be provided with full adherence to medical ethics and human rights principles, including informed consent, confidentiality and absence of coercion.

Implications of male circumcision scale up
At 60% efficacy, male medical circumcision is as good as any other available vaccines.

For those countries with generalised heterosexual AIDS epidemics, scale up of male medical circumcision is most advisable. Uganda, like many developing countries, fits in the category for rapid scale up of male medical circumcision for HIV-prevention.

Challenges
There is increased demand for services in most surgical sites in Uganda as a result of trickling news of the effect of male medical circumcision on HIV-prevention. Despite positive strides being taken by the Government regarding expanding and scaling up male medical circumcision services in Uganda, several challenges abound.

Circumcision is not recommended for HIV-positive men. They are already infected and there is no demonstrated benefit to their female spouses. Evidence suggests that there is increased risk of spreading HIV-infection if a circumcised HIV-positive man resumes sex before certified wound healing.

But should service providers deny male medical circumcision services to such a person? How about ethical, legal and human rights implications? The other side of this discussion is whether HIV counselling and testing should be compulsory or optional for persons seeking circumcision services for HIV prevention.

HIV test kits may not be enough. Only about 15% of adult Ugandans have accessed HIV-counselling and testing yet more than 80% of the adult population demand these services.

This is further complicated by the scarcity of human resources for health care delivery, especially regarding their numbers, skills and commitment; not mentioning the special circumstances of the hard-to-reach and hard-to-stay areas especially northern Uganda and Karamoja regions.

Follow up, monitoring and evaluation will certainly be additional challenges especially the need to ensure certified wound healing before resumption of sex.

Circumcised men may reduce condom use and increase the number of sexual partners because they think the risk of infection has reduced. Monitoring these tendencies is also a challenge.

Way forward
The impact of male circumcision in Uganda can only be possible if large proportions of men are circumcised.

It is, therefore, important to consider prioritising expansion of male medical circumcision services for younger males – say between ages of 12 to 30 years – among whom HIV-prevalence may still be low but incidence potentially likely to be high now or in the future.

Priority should also be given to HIV-negative men of any age, especially infants and young children, and those with indications of being at higher risk for HIV, such as those with sexually transmitted infections, long-distance truck drivers, men in discordant relationships, customers of commercial sexual workers, or those living in and around fishing communities.

The public should understand that male circumcision offers partial protection against HIV transmission from females to males.

The Government and partners should prepare the health system to provide safe, accessible and equitable service to those that need it, leaving prioritisation and rationing for the future. The benefit from circumcision is relative and not absolute.

The writer is a Public Health Consultant and an Expert on HIV/AIDS

http://www.newvision.co.ug/D/8/459/643147

African men lining up at circumcision clinic

John Lauerman, Bloomberg
Published: Saturday, August 02, 2008

On a typical day, Robert Bailey has 20 to 30 men waiting to be circumcized at his clinic in Kisumu, Kenya. The men are enduring the pain because they don't want to get AIDS.

Since a study by Bailey in 2006 found the operation drops the HIV infection rate in men by 60 per cent, the procedure most often performed at birth has become a popular elective surgery among grown men in southern Africa.

The push has been fuelled by $16 million from the U.S. for clinics, personnel and procedures, funding expected to double this year, and $10.8 million from the Bill & Melinda Gates Foundation.

The operation, in which skin covering the end of the penis is removed, may help lower infections among men of the traditionally uncircumcized Luo tribe by more than two-thirds, to five per cent, said Bailey, who runs the Nyanza Reproductive Health Society Clinic. Widespread use could prevent 5.7 million African infections and three million deaths over 20 years, according to the United Nations.

"It sounds stranger than fiction," said Kevin DeCock, director of HIV/AIDS at the UN's World Health Organization in Geneva. "Surgery to protect against an infectious disease is such an unfamiliar concept."

Researchers and advocates will discuss how to promote circumcision at the 17th International AIDS Conference in Mexico City next week, where more than 25,000 will gather.

AIDS experts are looking for cost-effective, reliable ways to reduce 2.7 million HIV annual infections. HIV vaccines and preventive gels have failed and some have even appeared to raise infection rates, and while condoms are effective, they work only when people have and use them, said Daniel Halperin, a Harvard School of Public Health researcher in Boston.

'One-time investment'

"Circumcision is a one-time investment, highly effective, and may make much more of an impact than any of these measures," he said in a telephone interview.

Bailey, a 61-year-old American, says he wants to overcome traditional ethnic views of circumcision.

While the Luo Council of Elders, an advisory body that can sway public opinion on religious and cultural issues, doesn't oppose circumcision, it has said a campaign encouraging the procedure would be inappropriate.

"We need to emphasize that circumcision isn't being promoted for reasons of culture and religion, but just medicine and health," he said.

Bailey, an anthropologist and epidemiologist at the University of Illinois at Chicago, endured 15 years of ridicule for his pet project, he said. People laughed openly when he gave a talk on the topic in Entebbe, Uganda, in 1998.

"I'd present my data and people would act like 'That's a quaint idea, let's move on,"' he says. "Now that we have the evidence that circumcision works, young men are actively seeking the services."

The Luo tribe is Kenya's third-largest, with more than three million living in western Kenya. After opening his clinic in 1997, Bailey started charging about $5 for the service and now does it free. About 65 per cent of young men in the region are unemployed, he said.

Nick Owuor, a 21-year-old Luo from Kisumu, said he had the five-minute procedure in Bailey's clinic this month to ward off sexually transmitted infections.

"The pain was pretty severe for about an hour," Owuor said. "But it's worth it."

In 1995, Bailey stumbled on a 10-year-old study suggesting circumcized men were less likely to catch HIV from prostitutes.

He spent years trying to prove a link, and says he thinks it can save millions of men in Africa, where about 22 million of the world's 33 million people infected with the AIDS virus live.

The pocket between the foreskin and the tip of the penis gives viruses and bacteria a spot to grow, and circumcision eliminates it. The foreskin has also been shown in studies to be rich cells that carry HIV into the body, said Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases.

Since Bailey's 2006 study, more African health leaders are trying to raise circumcision rates, said Agnes Binagwaho, executive secretary of Rwanda's National Commission to Fight AIDS, in an interview last month at the UN in New York.

"In our culture, there was no male circumcision," Binagwaho said. "Now the information is out there and people are demanding it."

"Read source article online"

RWANDA: Military to lead the way in male circumcision

KIGALI, 3 July 2008 (PlusNews) - The soldiers in the Rwanda Defence Force (RDF) will be the first men to benefit from a government policy to use male circumcision as a tool in the fight against HIV/AIDS, according to senior health officials.

Early in 2008, the Rwandan Ministry of Health declared its intention to include circumcision – scientifically proven to reduce a man's risk of contracting the virus from an infected sexual partner by as much as 60 percent – in its HIV prevention programmes. The voluntary circumcision programme is expected to start in August.

"We will use the military as role models for the rest of the population – they are adult enough to give consent, and if young men see that soldiers are willing to suffer the pain of circumcision, they will also get the courage to do it," said Dr Agnes Binagwaho, executive secretary of Rwanda's national AIDS commission (CNLS).

"After the military we will concentrate on students and, finally, on the general population; eventually we hope to move on to circumcising new-born babies, as long as research proves that it is advantageous and cost-effective to do so."

Unlike many other cultures in the region, Rwandan men and boys are not circumcised as a rite of passage, so it is unclear exactly how many men are circumcised but the number is presumed to be low. Research is underway to determine the percentage of men eligible for circumcision.

Rwanda's Centre for Infectious Disease Control and Prevention, known as TRAC PLUS, is to conduct a 'knowledge, attitude and practice' survey in the army to determine the level of awareness-raising needed, followed by a similar survey among the general population ahead of national rollout of the programme in 2009.

"The survey will ask questions like whether or not they know what circumcision is, whether they can name its advantages or disadvantages, whether they will continue to use condoms following circumcision, and so on. After that, CNLS will be responsible for information, education and communicating the message of circumcision to the public," said Elévanie Nyankesha, HIV prevention coordinator of TRAC PLUS.

"Our national public awareness campaign is due to start in July [2008] and will make it clear that circumcision cannot replace any of our existing prevention strategies – education, abstinence, faithfulness to a single sexual partner and correct and consistent use of condoms," Binagwaho told IRIN/PlusNews.

"People must be made aware that although circumcision is beneficial, there is still a 40 percent risk of HIV transmission, so they must know that it must be used in conjunction with another HIV prevention method, such as condom use," she said.

HIV prevalence in the RDF is estimated at between two and three percent - slightly lower than the national average of three percent. Intense prevention activities have been carried out since the mid-1990s, and barracks and military hospitals are plastered with billboards and posters urging soldiers to use condoms and be tested for HIV.

"We recently interviewed 70 men at one of the army's VCT [voluntary counselling and testing] centres and, surprisingly, it turned out that 55 of them had already been circumcised either for hygiene reasons, to prevent other diseases or because they believed it would improve their sexual performance," said Dr Charles Murego, director of medical services in the Ministry of Defence.

The circumcision campaign is to be rolled out gradually over a long period, because the 35,000-strong RDF could not afford to have hundreds of men incapacitated at the same time: "We will circumcise, say, 50 soldiers per week – it would be too dangerous to carry out mass circumcision in the army."

The RDF will also encourage former rebels undergoing disarmament, demobilisation and reintegration to undergo circumcision as they prepare to re-enter civilian society.

"We need to train medical staff – doctors, nurses and clinical officers – at our military hospitals, get the necessary equipment and then start the procedures," Murego told IRIN/PlusNews. The RDF has three military hospitals around the country.

Rwanda has more than nine million people, but only one doctor for every 50,000 people and one nurse for every 3,900 people, so increasing the number of medical staff able to perform the procedure is vital to the success of the programme. Nyankesha said doctors who had recently received training in Zambia would start training local practitioners at district level.

The circumcision programme will be funded by, among others, WHO and the UN Children's Fund, and carried out according to United Nations World Health Organisation (WHO) guidelines.

http://www.plusnews.org/Report.aspx?ReportId=79085

Uganda: Aids - High Time Men Got the Cut

The Monitor (Kampala)

EDITORIAL
18 May 2008

The campaign to have male circumcision as one of the major tools in the fight against the spread of HIV is gaining momentum by the day.

The latest call comes from policy analysts at two leading American universities. They propose that male circumcision coupled with reduction in number of sexual partners should become the focus of prevention efforts in countries such as Uganda with generalised HIV epidemics.

According to the researchers - from the University of California and Harvard University - male circumcision and reducing multiple sexual partnerships, two interventions currently getting less attention and resources, would have a greater impact in tackling the Aids pandemic.

When in 2006 initial findings of research into male circumcision in Uganda, Kenya and South Africa showed at least a 60 percent reduction in HIV risk, the trials were stopped early because it was not ethical to withhold the clearly proven benefits of this simple surgical procedure. Following the findings, a Monitor survey showed an increase in the number males seeking medical circumcision at various health units Kampala.

While it was anticipated that a policy would be put in place as per the recommendations of the researchers, nothing has happened. Even more strangely, President Museveni, a known lover of science, appears to be dithering or simply ignoring the evidence.

He was quoted last week saying he would not promote male circumcision as a means to prevent HIV transmission unless scientific evidence on its effectiveness was available. What more scientific proof do you want, Mr President?

And yet this President's blessing matters. Mr Museveni is credited internationally with leading the way in fighting HIV/Aids through the promotion of abstinence, faithfulness to one's partner, and condom use - the so-called ABC strategy.

And while we sleep, other countries are moving full-steam ahead and will soon overshadow Uganda on possibly the only front where our international credentials are not in dispute. In countries like Rwanda, where the research was not conducted, things are happening. President Paul Kagame is already promoting voluntary circumcision as his government works on a policy.

We all acknowledge the importance of ABC and treatment of sexually transmitted infections in controlling HIV infection, plus tackling related challenges such as domestic violence and poverty. Work should continue in all these areas.

But by no means should it end there. Let the government accept the science and promote male circumcision in Uganda where 135,000 people get infected with HIV every year.

http://allafrica.com/stories/200805190648.html

The impacts of male circumcision in Africa

Jamie Gajewski
Issue date: 5/2/08
The Lawrentian

Wednesday, Apr. 23 at 7 p.m. in Wriston Auditorium, Professor Robert C. Bailey lectured on male circumcision to a curious audience as part of the Bioethics Lectures Series sponsored by the Edward F. Mielke Foundation. Bailey prepared his audience by stating that his lecture on male circumcision ''usually makes people squirm.''

Bailey is a professor of epidemiology, the study and detection of epidemics of infectious disease, at the University of Illinois at Chicago. During research, he particularly places an emphasis on ethical behavior. Bailey's projects have taken him to far away places such as Thailand, Ivory Coast, Kenya and the Democratic Republic of the Congo. However, according to Lawrence's own Associate Professor of Anthropology Mark Jenike, Bailey ''has never been this far north before.''

Since the worldwide onset of the AIDS epidemic, over 40 million people have been infected with HIV, 68 percent of those residing in the sub-Saharan region of Africa. Coincidentally, these countries have some of the lowest rates of male circumcision in the world. Ironically, many of the hardest hit countries were originally societies that practiced male circumcision until British colonists forced them to stop the procedure. Worldwide, only about 30 percent of males are circumcised.

Through observational studies, it was concluded that male circumcision protects against HIV acquisition. Areas with high percentages of circumcised males, such as the United States and Muslim countries, reported some of the lowest occurrences of AIDS in the world. After the observational studies' results were reported, the World Health Organization and other groups called for more evidence.

Bailey joined a team of researchers and performed clinical trials in Kisumu, Kenya on 2,784 Kenyan men between the ages of 18 and 24. The men were randomly assigned to groups and either received surgery, or did not. The men were recruited from high risk groups such as STD clinics, testing centers, soccer leagues and even boda boda drivers, a type of bicycle taxi.

All men were given counseling, tested for HIV at three month intervals for two years, and asked to fill out questionnaires on their sexual activity. At the end of the trials, the evidence was astounding, and almost equivalent to the observational studies: male circumcision provided a 59 percent protective effect against HIV.

How exactly does circumcision protect against HIV acquisition? To answer this question Bailey annotated several brightly colored images, saying, ''I know foreskin is not pretty, but these slides are pretty.'' In uncircumcised males, the inner foreskin is extremely susceptible to HIV when the penis is erect. However, in circumcised males, the same area is protected by a layer of carotene that blocks the virus. Unfortunately, male circumcision only has a protective effect in males engaging in vaginal intercourse because the anus is susceptible to HIV much like the inner foreskin.

During a 2007 World Health Organization and UNAIDS Consultation held in Switzerland, Bailey and his team presented their trial data. The presentation was so persuasive that male circumcision was considered a necessary component of ''an HIV prevention package.''

The protective effect for heterosexual males was compared to a vaccine and other health benefits were observed, such as a lower incidence of urinary tract infections, some cancers and certain STDs.

On the other hand, the trial evidence presented at the consultation raised questions pertaining to safety during the procedure, increased risk behavior, effectiveness as a tool for prevention and cost. Risky sexual behavior increased in the circumcised test group within one month after surgery, much like, "someone wanting to try out a shiny, new car." However, due to counseling, both groups' risk behaviors decreased over the two year period.

Towards the end of the lecture, Bailey presented some of the ethical issues involved with circumcision. In surgical procedures, informed consent and protection of assault are crucial to proceeding in an ethical manner. In the Jewish and Muslim traditions, male infants are circumcised shortly after birth. Obviously, an infant cannot consent to this procedure after only eight days of life. Religious and cultural traditions often take precedence over human rights.

Likewise, a physician will often perform a procedure without a child's consent if it has identifiable medical benefits. Male circumcision is not yet recognized as having a clear medical benefit. Although Bailey presented both sides of the debate, he also stated that personally he does not have a clear position because while he believes there are medical benefits, he is hesitant about violating human rights.

Although an increase in male circumcision rates in sub-Saharan Africa will prevent thousands of new HIV infections and cases of AIDS each year, the impact will not be felt in the United States. In the US, most cases of HIV occur between homosexual couples and through the use of injected drugs, making it extremely important to know the status of your partners and use condoms every time.

Although male circumcision began on the African continent, it is rarely practiced in African countries today. As the world awaits the creation of an HIV vaccine, something that Bailey does not believe any of us will see in our lifetimes, the protective effect of male circumcision for sub-Saharan Africans seems to be a potential source of hope for a hopeless epidemic.

http://media.www.lawrentian.com/media/storage/paper409/news/2008/05/02/Features/The-Impacts.Of.Male.Circumcision.In.Africa-3358269.shtml

South Africa: Circumcision an 'Opportunity To Take Great Strides Forward' Against HIV

Inter Press Service (Johannesburg)

INTERVIEW
30 April 2008

Results from trials in South Africa, Kenya and Uganda in 2006 showed that male circumcision reduced the transmission of HIV from women to men by up to 60 percent. On the basis of these results, the Joint United Nations Programme on HIV/AIDS and the World Health Organisation have recommended that countries encourage men to be circumcised.

But, promoting this procedure is not without risk.

There is a danger that men may assume circumcision provides complete protection from HIV, and take no further steps to protect themselves. During the six to eight week healing period for the procedure, men are also more vulnerable to infection than before. In addition, many of the procedures are currently performed by traditional circumcisers under conditions that are often unsterile and which may permit HIV transmission.

To get a sense of how these constraints can be negotiated, IPS editor Kathryn Strachan talked to Mark Heywood, director of the AIDS Law Project at the University of the Witwatersrand in Johannesburg, South Africa. Heywood is also deputy chair of the South African National AIDS Council.

In light of what the trials have shown, what do we need to do now?

Large parts of Southern Africa have no tradition of male circumcision, so we need to get information out about the benefits of circumcision. Information about circumcision has already been widely publicised, but there is a lot of confusion and misunderstanding. What we need now is for the Department of Health to provide accurate, high quality information on the benefits of circumcision. This is not happening in South Africa.

How should a programme of circumcision be introduced?

Male circumcision needs to be integrated into a wider programme of male sexual and reproductive health, and it needs to be promoted as just one part of HIV prevention. Promoting it in this way it gives us an opportunity to talk about male sexual health, something that very rarely happens. A comprehensive approach also provides an avenue to HIV testing and counselling services and broader HIV prevention measures, and in doing this it encourages men to take responsibility for their health and to make informed choices.

We need to avoid having circumcision introduced in a way where men simply go into a health facility, undergo the procedure and leave. Carrying it out in a way that is separated from a wider HIV programme means that men could go back into the community without the correct understanding of circumcision as a preventive measure.

What role does tradition play in promoting circumcision?

Culture and tradition are complex issues and we still have to figure out how to approach them. What we need is to have accurate information placed in the public domain and then to leave it to individual men to make the decisions themselves, based on the information they receive. And, we need a social and community driven prevention strategy to assist men who elect to have the procedure. What we want to avoid is putting pressure on one group to be circumcised because another group is.

In light of what you've said about the best way of proceeding, what is the next step that should be taken?

The next step is to get a policy through the South African National AIDS Council, which is the highest advisory body to government on AIDS. In civil society there is a lot of confusion surrounding circumcision and this needs to be sorted out, and in government there is resistance...But circumcision presents an opportunity to take great strides forward in reducing the number of new infections, and what we need now is public messaging that provides clear and unambiguous guidance that speaks to the needs of those who elect (to have) circumcision.

http://allafrica.com/stories/200804301028.html

Rwanda continues with male circumcision roll out.

Rwanda To Launch Campaign Aimed at Addressing Circumcision Myths, Encouraging Procedure in Effort To Prevent HIV

[Feb 26, 2008]

Health authorities in Rwanda are planning to launch a nationwide campaign this year aimed at addressing myths about male circumcision and encouraging men to be circumcised in an effort to prevent the spread of HIV, McClatchy/Miami Herald reports (Bengali, McClatchy/Miami Herald, 2/24).

Rwanda announced plans to launch the campaign in September 2007. According to final data from two NIH-funded studies -- conducted in Uganda and Kenya and published last year in the journal Lancet -- routine male circumcision could reduce a man's risk of HIV infection through heterosexual sex by 65%. The results of the Uganda and Kenya studies mirrored similar results of a study conducted in South Africa in 2005. In response to the findings, the World Health Organization and UNAIDS in March 2007 recommended the procedure as a way to help reduce transmission of the virus through heterosexual sex (Kaiser Daily HIV/AIDS Report, 1/24).

The campaign will initially target the army, police officers and university students, Innocent Nyaruhirira, the country's health minister, said. The campaign will aim to reduce the cost of the procedure, which can be as much as $55 at private hospitals, as well as ensure it is covered by basic health insurance policies.

According to McClatchy/Herald, many men in the country have already received the procedure. Justin Gatete -- a nurse at a clinic in Kigali, Rwanda's capital -- said he performed more than 1,000 circumcisions last year.

"We're not going to wake up one morning and have all men be circumcised," Anita Asiimwe, director of Rwanda's Treatment and Research AIDS Center, said, adding, "We need to see how best to implement this."

Health experts from the U.S. are helping Rwandan officials develop the campaign. The Bush administration has said it would allocate funds in the President's Emergency Plan for AIDS Relief to make circumcision more accessible in Africa. Kenya, Swaziland and Zambia have announced plans to make the procedure available in public clinics.

http://allafrica.com/stories/200802260731.html

Circumcision and Human Papillomavirus Infection in Men

J Infect Dis. 2008 Feb 19

Hernandez BY, Wilkens LR, Zhu X, McDuffie K, Thompson P, Shvetsov YB,
Ning L, Goodman MT.
1Cancer Research Center of Hawaii and 2University Health Services,
University of Hawaii, Honolulu.

Background:
Lack of circumcision has been identified as a risk factor for male genital human papillomavirus (HPV) infection, although this association has not been consistently supported.

Methods:
Specimens for HPV testing were collected from a cohort of 379 (primarily heterosexual) adult males. HPV prevalence in the glans pe nis and coronal sulcus, penile shaft, scr otum, semen, and urine was compared by circumcision status.

Results:
Overall, HPV DNA prevalence ranged from 6% in semen to 52% in the penile shaft. The prevalence of any HPV infection in the glans/corona was significantly higher in uncircumcised men (46%) than in circumcised men (29%) (odds ratio [OR], 1.96 [95% confidence interval {CI}, 1.02-3.75], adjusted for demographic characteristics and sexual history). Uncircumcised men also had an increased risk of oncogenic HPV infection (adjusted OR, 2.51 [95% CI, 1.11-5.69]) and infection with multiple HPV types (adjusted OR, 3.56 [95% CI, 1.50-8.50]). Among uncircumcised men, HPV prevalence in the foreskin (44%) was comparable to that in the glans/corona, and type-specific positivity was observed between the 2 sites.

Conclusions:
Uncircumcised men have an increased risk of HPV infection,including with oncogenic HPV, specifically localized to the glans/corona, possibly because of its proximity to the foreskin, which may be particularly vulnerable to infection.

Circumcision: SA men ‘not snipped properly’

BOBBY JORDAN
Published:Feb 10, 2008

UP TO half of circumcised South African men did not undergo the procedure “properly”, leaving them more at risk of contracting HIV than men who went under the scalpel in a clinical setting.

This was one of several findings presented to an international conference in the US this week, attended by the world’s top HIV/Aids researchers.

Recent research worldwide has shown that male circumcision may decrease the chance of contracting HIV, which targets cells in the foreskin.

The World Health Organisation last year recommended circumcision as an effective intervention in the fight against Aids.

French researcher Dr Bertran Auvert of Versailles University suggested this week that 40% to 50% of circumcisions in Southern Africa were only “ritual” or “partial” circumcisions — where the foreskin was not completely removed.

HIV trials conducted in South Africa, Kenya and Uganda showed that only clinical circumcision could reduce the risk of males getting HIV, said Auvert.

“What I know is that not all who say that they call themselves ‘circumcised’ are clinically circumcised,” he said. “In fact their penises are completely intact.”

Of the estimated 165 million men in Sub-Saharan Africa, about 54 million (33%) were uncircumcised, Auvert said.

He detailed a plan for a massive circumcision roll-out in sub-Saharan Africa.

http://www.thetimes.co.za/News/Article.aspx?id=702569

Now we know: Circumcision saves lives

Now we know: Circumcision saves lives

Larry Krotz, National Post
Published: Tuesday, February 05, 2008

We can all be rightly proud as Canadians that Canadian scientists, a Canadian university, and, yes, that entity in perpetual short supply, Canadian research dollars, played a substantial role in what has been designated by TIME magazine as one of the biggest medical breakthroughs in 2007. Number two on their recently published top-10 list is the discovery that circumcised men are "at least 51% less likely than uncircumcised men to acquire HIV during sex with women."

In Africa, where the clinical trials that reached this conclusion were carried out, this is very big news indeed because heterosexual sex is the main form of transmission of the deadly virus. Due to tribal customs, many African men remain uncircumcised. If they can get access to circumcision surgery, it is likely to have a dramatic effect on HIV rates.

In the late 1980's, Dr. Stephen Moses of the University of Manitoba, already involved in AIDS research in east Africa, had a hunch there might be a correlation between male circumcision and HIV infection rates. He and another Manitoban, Dr. Francis Plummer, had seen how a variety of sexually transmitted diseases created portals for HIV entry and how circumcised men had fewer STDs. But it took until 2002 for Moses to muster the right partners, the ideal study group, and enough interest from funders to support a properly controlled clinical trial.

With Dr. Bob Bailey of the University of Illinois in Chicago and a local partnership with the University of Nairobi, they opened a clinic in the west Kenya town of Kisumu in order to test the hypothesis. The Canadian Institutes of Health Research (CIHR) paid to build the clinic and, with the U.S. National Institutes of Health (NIH), promised support for five years while the scientists set out to find 2,800 young men from the Luo tribe who might volunteer to be research subjects.

Theirs was one of three such studies. Another by French scientists had been set up in Orange Province, South Africa, and a third took place in Uganda. Early on, Moses and Bailey told me how the work of all three was perceived as long-shot, peripheral research while the major efforts in the AIDS war were going into the search for a vaccine and new antiretrovirals.

The researchers experienced their share of difficulties, most of them having to do with the tricky business of carrying out complicated scientific research in a distant corner of Africa.

They had to overcome local prejudices against circumcision and labour hard simply to keep track of their 2,800 research subjects for two years. Their clinic staff were continually dealing with small crises of behaviour -- one young man had sex two times within eight days of his surgery, something he had been adamantly counselled against, while another rode his bicycle home after the surgery, which did him no good.

The early numbers were so good that some argued it was potentially unethical to require control groups to remain uncircumcised even for the duration of the studies. In 2005, the South African study was halted. Eighteen months later, in December 2006, and a year shy of completion, the Kenyan and Ugandan projects were also halted. The scientific method had been trumped by ethics.

As it was, the Manitobans and the University of Illinois already had proved their point by publishing their findings in the prestigious scientific journal Lancet. Instantaneously, Moses and Bailey moved from the fringes of the formerly sceptical AIDS-research world to the very centre. Bill Clinton singled out circumcision in his speech to the World AIDS conference, Bill Gates turned on the money tap, and finally came anointment by TIME magazine. Henceforth, circumcision as a preventative strategy will be a player along with vaccine research, condom use and antiretrovirals. "In areas where HIV-1 prevalence constitute a generalized population epidemic," stated an editorial in the Lancet, "male circumcision could have a dramatic life-saving effect."

CIHR, the government of Canada's health-research funding agency, is properly claiming bragging rights -- achieved at a bargain-level investment of $2.7 million. This is but a taste of the sort of success we could achieve with a greater commitment: Though it spends more than twice as much as it did in 1999, CIHR's current budget of $700-million is still outstripped 40 times over by the equivalent U.S. body, the National Institutes of Health, which has a budget of US$28-billion.

Dr. Moses and Dr. Plummer have done Canada proud, and are showing how much good we can do when we set our minds -- and money -- to the task.


http://www.nationalpost.com/opinion/story.html?id=286194&p=2