Eulalee Thompson Evidence that male circumcision has a protective effect against the human immunodeficiency virus (HIV) infection in men is forcing world health experts to recommend it as a prevention strategy in the fight against HIV/AIDS.
At the end of last month, after expert consultation in Montreux, Switzerland, health experts from the World Health Organisation (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) released documents stating that "based on the evidence presented, which was considered to be compelling, experts attending the consultation recommended that male circumcision now be recognised as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men".
The evidence to which they referred came from three randomised controlled trials on the African continent examining the potential link between male circumcision and lower risk of HIV acquisition. The first trial, funded by the French Agence Nationale de Recherches sur le SIDA, was carried out in Gauteng province in South Africa among men aged 18 to 24 years. The findings, reported in July 2005, showed a reduction of 60 per cent or more in the risk of acquiring HIV infection among circumcised men.
The other two trials, funded by the U.S. National Institutes of Health, in Rakai District, Uganda, and in Kismu, Kenya, were scheduled to end in July and September 2007 respectively; the data from these studies were important to validate those from the South African trial. The consultation last month indicates that the last two studies validate the earlier findings that male circumcision does reduce the risk of heterosexually acquired HIV infection in men by about 60 per cent.
Tight foreskin
These scientific results confirm what had been observed for many years - that in some geographical areas, where circumcision was ordinarily performed (maybe for religious or ethnic reasons), there had been lower HIV prevalence.
Circumcision is the surgical removal of the foreskin of the penis. The operation which requires the use of trained medical staff and, in the case of countries like Jamaica, scarce operating theatre facilities, is usually performed on newborns for religious beliefs or personal preferences of the parents. Health experts indicate that the main medical reason for circumcision is to remove an unusually tight foreskin that is obstructing the flow of urine.
It should be noted clearly that these three trials only tested the HIV risk and acquisition in circumcised men and did not assess the risk of HIV transmission to male or female partners of circumcised men. A trial to assess the impact on female partners of circumcised men is currently being undertaken by Johns Hopkins University in Uganda with results scheduled for later this year. Men to men transmission have been studied but not in trials.
Cautionary notes
There are, of course, several cautionary notes which the world health experts have pointed to:
1Male circumcision offers partial protection from HIV infection and should always be considered as part of a comprehensive HIV prevention package.
2 Counselling of men and their sexual partners is necessary to prevent them from developing a false sense of security and engaging in high-risk behaviour that could undermine the partial protection of male circumcision.
World health experts agree that additional research is also needed to:
1Assess the impactof male circumcision on sexual transmission from HIV-infected men to women.
2Assess the impact of male circumcision on the health of women for reasons other than HIV transmission (for example, lessened rates of cancer of the cervix).
3Assess the risks and benefits of male circumcision for HIV-positive men.
4Assess the protective benefit of male circumcision in the case of insertive partners engaging in homosexual or heterosexual anal intercourse.
5Assess resources needed for, and most effective ways, to expand quality male circumcision services.
eulalee.thompson@gleanerjm.com
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