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.
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.
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.
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.
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