Monday, May 5, 2008

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.