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