Should Male Circumcision be Embraced as an HIV Preventive Measure?
Will increased circumcision help?
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First published: March 14, 2007
Whenever talks turns to HIV/AIDS anywhere in the world, Uganda will be mentioned. When the disease was first discovered, Uganda was among,if not the most, affected country (ies) with over 30 percent of the population infected with the deadly virus. When the infection rate in Uganda went down due to the government's Abstain, Be faithful, use Condoms (ABC) strategy, again Uganda became the center of world attention this time with kudos being dished out.
If you may recall, recently in December 2006 the latest UNAIDS/WHO Report was published and it showed that Uganda had slid backwards after making progress earlier in containing the disease that has claimed millions of people worldwide. Uganda again grabbed international attention. Indeed, many researchers have expressed a lot of interest in Uganda with research results published in many medical journals on the state of HIV/AIDS in Uganda. The latest prominent studies include one published on the 24th of February 2007 in The Lancet showing that circumcised men in a Kenyan trial had 53 percent fewer HIV infections than uncircumcised men while the infection rates in Uganda stood at 48 per cent.
A day before the publication of the study, the United Nations health agencies announced that they are to convene an international meeting of AIDS experts to examine the latest findings in early March 2007. The meeting this month is expected to discuss cultural and human rights considerations, the risk of complications from the procedure performed in various settings, the potential to undermine existing protective behaviors and strategies, and the fact that the ideal and well-resourced conditions of a randomized trial are often not replicated in other settings. In Uganda, Dr Sam Okware, director of health services says the Health Ministry is still assessing the findings on male circumcision to see how they could be factored into the country's general prevention strategy just the way some people have been proposing.
But as the Government of Uganda ends its assessment and the UN comes up with an official position after the consultations, male Ugandans are dashing to health centers to get rid of the foreskins on their penises as a measure to reduce the chances of them contracting the HIV. According to PlusNews, in neighboring Kenya, requests for male circumcision in the Nyanza Province have tripled since the initial publication of the NIH studies in December 2006.
According to Reuben Okioma, a physician at New Nyanza Provincial District Hospital, there has been a threefold increase in requests for the procedure since the studies were released. Like many tribes in Uganda, people in this province do not traditionally practice circumcision. Okioma says the findings in the study challenge the traditional views of the community, adding that hospitals in the region have been able to meet the increased demand and many more men are likely request for the procedure if it became available at no cost to them.
The fear, according to health experts, is that these people may misinterpret the findings to mean "circumcision prevents the spread of HIV/AIDS" and consequently start engaging in unprotected sex. In fact, some analysts are convinced that misconception among some members of the Ugandan population that ARVs cure HIV/AIDS could be the cause of Uganda's backsliding in HIV/AIDS prevention efforts.
According to the study published in the March 2007 issue of Annals of Epidemiology, the authors say that unhygienic conditions and poor standards in traditional circumcision procedures expose patients to infection from blood-borne diseases including HIV/AIDS. President Yoweri Museveni of Uganda agrees and calls for continued emphasis on behavioral change instead. "The only way to avoid getting infected is to avoid having illicit sexual affairs. Why are Muslims and Bagisu dying? Who beats the Bagisu when it comes to circumcising men?" Among the Bagisu, a tribe in eastern Uganda, every male, between adolescence and manhood, must be circumcised. The cultural circumcision is done in the open during daytime, in the presence of witnesses.
The Bagisu dancing to inemba tubes-
a dance performed after male circumcision
President Museveni, who has won accolades on behalf of his government and his personal efforts in containing the pandemic, says that promoting circumcision as an approach to fighting HIV/AIDS could increase the rising levels of HIV prevalence because of confusing messages. "These days, there are many confusing messages. One of them is that if you are circumcised, you are less likely to catch AIDS even if you behave recklessly. Now what sort of message is that?" the president stated recently, adding that such messages send the wrong signal to the masses and cause apathy in the fight against HIV/AIDS.
Dr Godfrey Kigozi, one of the investigators in the Ugandan study agrees with the President of Uganda, pointing out that the study published in The Lancet on February 24 2007 highlighted the protective effect of male circumcision on transmission of the virus, but emphasized that it did not erase the risk altogether. "When you say circumcision reduces acquisition, it does not mean it eliminates HIV/AIDS," Kigozi said. "It is just one component in our arm of prevention. If you are circumcised, then it is fine, but if you practice safe sex or abstain, that is better."
The message that health experts are firmly putting across at this time is that you cannot depend on circumcision to protect you. This is because if you get circumcised and engage in unsafe sexual practices you may reduce the chances but you cannot prevent HIV/AIDS infection.
Opponents of circumcision as a measure of preventing the risk of HIV infection also argue that it may not be practiced in many cultures where circumcision is not a norm. They quote former UNAIDS executive director Peter Piot as declaring on December 19th 2006 that African countries should prepare to perform male circumcisions on a large scale but did not say whether UNAIDS had plans to promote male circumcision in high-HIV prevalent India 'where the issue is sensitive for the Hindu and Muslim communities.' That is why some analysts say that even in African countries (including Uganda) where male circumcision may be a sensitive issue among some communities that do not traditionally perform circumcision may backfire.
Circumcision could reduce HIV infections at landing sites.
As the debate continues, some experts are recommending that circumcision be added to Uganda's ABC strategy which calls for Abstinence, Being faithful and using Condoms if you cannot abstain or be faithful. David Serwadda, the director of the Institute of Public Health at Makerere University told members of the Parliamentary Committee on HIV/AIDS recently that the Government of Uganda needs to create a policy that recognizes circumcision as an effective HIV prevention method alongside the ABC strategy. "We want the government to generate a policy for this service to be provided to the public in a safer manner," Serwadda says, adding that if the government does not establish such a policy, some people will undergo risky circumcision operations and thus have an increased risk of HIV infection.
"Circumcision has very important policy implications, and if for some reason the policy is not formulated, people will go to all categories of people to circumcise them," Serwadda is quoted by the Daily Monitor newspaper. Serwadda calls on the Ugandan Parliament to engage in the circumcision debate as the government formulates a five-year strategic plan on HIV/AIDS.
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First published: March 14, 2007
Gideon Munaabi is a journalist and public relations practitioner with Ultimate Media Consult (U) Ltd. He has been and continues writing widely for different publication locally and internationally. He is a founding member of Ultimate Media Consult (U) Ltd and is currently the chairman of the organisation.