Cutting edge: Male circumcision and HIV

Date: January 1, 1970
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Male circumcision (removal of the foreskin of the male penis) is increasingly gaining currency as part of strategies to reduce HIV-infection. In sub-Saharan Africa, the worst affected region in the world, researchers say that male circumcision (MC) could prevent six million new infections in the next two decades. Yet there is need to examine just how far circumcision offers protection for men and women.

Despite the flurry of attention since the release of research results, the topic, like most issues of sexuality, remains mostly taboo in social circles. Although evidence points to the procedure as has having positive affects on HIV reduction, the procedure itself does nothing to address the many social factors of HIV prevalence – lack of access to health care for many people, stigma and cultural practices that reduce awareness and discussion, and gender imbalances.
According to fact sheet produced by the Centers for Disease Control, a United States based public health agency that aims to promote health worldwide, three randomised controlled clinical trials were conducted in Africa to determine whether circumcision of adult males will reduce their risk for HIV infection. In these studies, men randomly assigned to the circumcision group had a 60% (South Africa), 53% (Kenya), and 51% (Uganda) lower incidence of HIV infection compared with men assigned to the wait-list group for circumcision at the end of the study.
The argument is that the inner surface of the foreskin contains Langerhans celles, which have HIV receptors, and is vulnerable to traumatic epithelial disruptions during intercourse. Second, an intact foreskin exposes a man to a greater risk of ulcerative sexually transmitted infections, which in themselves are a risk factor for HIV acquisition. Furthermore, the virus’ chances of survival might be higher in a warm, wet environment like the one under the foreskin.
According to the United States Agency for International Development, qualitative studies in Botswana, Haiti, Tanzania, Zambia, and Zimbabwe have revealed favourable attitudes toward MC in populations that do not traditionally practice circumcision. From 45 to 85 percent of uncircumcised men in surveys expressed interest in the procedure if it is safe and affordable.
In spite of the interest in male circumcision, it is not a magic bullet in the fight against HIV/AIDS. Many HIV activists and educators have expressed concern about over emphasising the strategy. Some men may be tempted to engage in unprotected sex because they perceive male circumcision protects them. Increased numbers of men engaging in unsafe sex will undoubtedly decrease any positive impact of increasing the numbers of circumcised men.
As well, male circumcision provides little or no protection against urethral sexually transmitted infections such as gonorrhea and Chlamydia, and certainly cannot prevent unwanted pregnancies. Another danger is that male circumcision can be risky or fatal if conducted by untrained personnel. Many health facilities in sub-Saharan Africa are in a shambles, putting great doubt on the efficacy of male circumcision.
Perhaps the most immediate worry is that if circumcision encourages men to have unprotected sex, the negotiating power of women, who are not protected at all from the procedure, will be threatened. While women may benefit from lower HIV prevalence in their partners in the end, until this strategy is well understood, it could significantly increase women’s vulnerability.
To be effective, circumcision needs to take place alongside promotion of condom use and faithfulness, and other traditional approaches in the fight against HIV and AIDS. To be successful, male circumcision must complement a massive investment into education and counseling programmes. There will be need for widespread and culturally sensitive dissemination of information that outlines the benefits and potential complications of male circumcision.
 Beyond all, as with most other HIV preventions strategies, we must continue to build discussions and mutual respect between sexual partners, and in our communities.
Masimba Biriwasha is the Africa Regional Campaigns, Communications and Policy Manager for Health & Development Networks. This article is part of the Gender Links Opinion and Commentary Service that provides fresh views on everyday news.

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