Male Circumcision

Sunday, August 10, 2008

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, 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.”

Friday, August 8, 2008

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.

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.

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

Sunday, August 3, 2008

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."

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