United Nations Backs Male Circumcision, African Leaders Reluctant to Adopt Recommendation
Worry that people who aren't qualified to perform it will rush forward to meet the demand.
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First published: April 5, 2007
After weeks of waiting and debating that has seen some African leaders (including President Yoweri Museveni of Uganda) downplaying the role of circumcision in HIV/AIDS prevention, the World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) have broken their silence. Some countries had resisted plans to make circumcision a public health policy until they had received WHO's advice. The day finally arrived on March 28, 2007, when the two international bodies recommended that African males living in the heart of the AIDS pandemic protect themselves against HIV by undergoing circumcision - medical advice that could lead to surgical procedures on tens of millions of males, from infants to elders.
Model studies suggest that male circumcision in sub-Saharan Africa could prevent 5.7 million new HIV cases and 3 million deaths over 20 years, the UNs World Health Organization (WHO) said, summarizing the findings of an experts meeting it convened in March together with the Joint UN Programme on HIV/AIDS (UNAIDS).
How male circumcision may prevent infection
Male circumcision removes part of, or the entire foreskin of a penis. If an intact foreskin tears during unprotected sex, it can provide an entry point for HIV, the virus that leads to AIDS. Under the foreskin are Langerhans cells, which are more vulnerable to HIV infection. The health experts say that male circumcision is the most potent scientifically proven protection in years against the AIDS epidemic; one study predicts that circumcision could avert up to 2 million infections over the next decade.
Three randomized controlled trials in Kenya, Uganda and South Africa provide strong evidence that male circumcision cuts the risk of heterosexually acquired HIV infection in men by about 60 per cent, supporting numerous observational studies showing that the correlation between lower HIV prevalence and high rates of male circumcision in some countries in Africa is, at least in part, a causal association. According to the World Health Organization, 665 million men, or 30 per cent of men worldwide, are estimated to be circumcised.
World Health Organization offers caution
The World Health Organization says that counseling men and their sexual partners is necessary to prevent them from developing a false sense of security and engaging in high-risk behavior that could undermine the partial protection provided by circumcision. The World Health Organization advises that circumcision should only be considered as part of a comprehensive prevention package that includes treatment for sexually transmitted infections, promotion of safer sex practices and provision and correct use of male and female condoms.
This is an exciting development, but this is only partial protection for men, says Catherine Hankins, UNAIDS's chief scientific adviser, adding that this does not mean that circumcision should be scoffed at, since it has not received a bad rap in a long time. Men and women who consider male circumcision as an HIV preventive method must continue to use other forms of protection such as male and female condoms, delaying sexual debut and reducing the number of sexual partners, she adds.
The WHO and UNAIDS are aiming the recommendations at men in countries with high rates of HIV prevalence spread heterosexually, mainly in southern Africa and parts of eastern Africa including Uganda where the rate of HIV prevalence is once again rising, according to the recent UNAIDS and Uganda AIDS Commission statistics. WHO and UNAIDS officials stressed that countries should offer circumcision in a package of services that includes HIV testing and counseling, promoting proper use of condoms, and counseling men on ways of reducing the risk of contracting HIV. The officials noted that circumcised men can still become infected, although their risk is lower than those who have not had the procedure, according to randomized trials involving several thousand men conducted over the last several years in South Africa, Uganda, and Kenya.
African governments reluctant...
Health experts say that the wait-and-see approach taken by many African governments has frustrated several public health specialists. I hear on a weekly basis, cases where officials in some ministries of health comment: Wow, this data is interesting,' and they are sending their own sons to get circumcised, or their spouses, or themselves, said Daniel Halperin, a senior research scientist at Harvard's School of Public Health, who for years has prodded health agencies to embrace circumcision as a way of slowing the spread of HIV. The elites are rushing out, ready to be circumcised, he said, but what is it going to take to put pressure on these people to make safe circumcision available to the poor guys?
The truth is that there hasn't been a great deal of preparation even though the first evidence of circumcision's protective values emerged more than 18 months ago, said David Alnwick , UNICEF's Nairobi-based senior HIV/AIDS adviser for eastern and southern Africa. He added that since circumcision emerged as a protective measure against the HIV infection, only six sub-Saharan African nations, where the pandemic is a big health disaster, have convened public meetings to discuss ways of expanding the services.
Experts argue that this is because these countries health systems are already overburdened and most developing countries have a dire shortage of health workers, while governments either don't have enough money to pay for population-wide circumcision or choose not to spend more on public health, creating a dependency on rich countries for donations.
Fears about post surgical complications
Dr. David Serwadda, Director of the Institute of Public Health at Makerere University, one of the leaders in the Ugandan circumcision trial, said that My worry is, as people rush to have this operation and people who aren't qualified to perform it will rush forward to meet the demand."
A study in Uganda found that 35 percent of all circumcisions performed by such people, including traditional healers, resulted in post surgical complications such as infections. In comparison, just 1.7 percent of circumcisions performed in the controlled trial in the country had complications. The UN bodies advise that wherever the circumcision service is offered, there should be training and certification of providers as well as careful evaluation of programmes. In view of the large potential public health benefit, the UN health bodies advise countries to consider providing the services free of charge or at the lowest possible cost to the client.
Dr. Michel Kazatchkine.
Dr. Michel Kazatchkine, who will become the Executive Director of the Global Fund next month and who oversaw the South African circumcision study, says that all new public health interventions may take time to catch on. We're 20 years into AIDS and we still have communities, constitutuencies and countries that are reluctant to make condoms freely available. People will find the 150 reasons not to go into circumcisions just as they opposed use of condoms.
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First published: April 5, 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.