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AFRO-NETS> Male Circumcision: Cutting the Risk?
Male Circumcision: Cutting the Risk?
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Bob Huff
American Foundation for AIDS Research, July 2000
<http://ww2.aegis.org/pubs/amfar/2000/AM000802.html>
Copyright c 2000 by the American Foundation for AIDS Research (amfAR)
and first displayed on amfAR's Treatment Directory web site
<http://www.amfar.org/td>). Organizations wishing to reprint or re-
distribute these materials should request authorization from amfAR's
Department of Treatment Information Services (212/806-1600).
--
Introduction
Lack of male circumcision has long been linked to the higher HIV
prevalence in Africa. First identified in the eighties, the associa-
tions between circumcision, sexually transmitted diseases (STDs) and
HIV transmission have been extensively studied.
At the XIII International AIDS Conference in Durban this July, more
evidence was presented supporting circumcision as a risk-lowering
factor for HIV transmission. What was surprising, however, were stud-
ies suggesting that adult male circumcision, if available, would be
an acceptable - even desirable - option for many African men at risk.
An intact (uncircumcised) penis is biologically different from a cir-
cumcised one. The foreskin (prepuce) is a folded-over flap of skin
and mucosa that covers the head (glans) of the penis. In intact boys,
the prepuce adheres to the glans until about the age of eight, when
it loosens and becomes retractable. The glans and the part of the
prepuce protecting the glans are mucosal tissue - similar to tissue
found in the vagina or mouth. During circumcision, the foreskin is
pulled back, a section of the prepuce is cut away and the glans is
exposed. After exposure, the mucosa of the glans and remaining pre-
puce begins to keratinize and toughen, eventually becoming like the
more durable form of skin found on other exposed parts of the body.
When mucosal tissue is irritated or inflammed, immune system scaven-
gers and other white blood cells are attracted to the area. These
cells, including macrophages and dendritic and Langerhans cells, are
the primary entry points for HIV infection. One theory of the protec-
tive value of circumcision proposes that the reduced area of exposed
mucosa affords less opportunity for HIV to enter the immune system.
There is also an observed relation between HIV transmission and the
prevalence of sexually transmitted diseases such as herpes simplex 2
(HSV-2), a cause of penile lesions. If uncircumcised men are more
easily infected with HSV-2 and other STDs, as many reports suggest,
then they may also become more susceptible to HIV infection.
On the other hand, some physicians have proposed that circumcised pe-
nises, lacking the 'gliding' mechanism of the intact foreskin, may
possibly cause more irritation to vaginal tissue during intercourse.
This would increase the chances for HIV transmission to women. Al-
though the biological mechanisms for a protective effect of circumci-
sion await more research, the observations of epidemiology studies
that find protective associations must be considered seriously. But
are these effects due to circumcision or to other behavioral factors?
Certain cultural or religious practices, such as washing the penis
after coitus, may themselves contribute significant protective bene-
fits incidental to circumcision. On the other hand, critics of cir-
cumcision have argued that daily washing of the uncircumcised penis
is unnecessary and may cause mucosal inflammation. Without evidence
from randomized controlled trials, blanket recommendations for
changes in cultural practices are risky.
In the meantime, well-established prevention messages about consis-
tent condom use and avoiding high-risk encounters continue to be
valid advice for men whether they have foreskins or not.
New at the Durban Conference
In the 1980s, Dr. Francis Plummer of the University of Nairobi ob-
served that uncircumcised men were eight times more likely than cir-
cumcised men to have had genital ulcers. Additionally, uncircumcised
men with genital ulcers in his studies had a 50% chance of becoming
infected with HIV after only a single sexual encounter with an in-
fected prostitute.
Twelve years later, Anne Buve of the Institute of Tropical Medicine
in Belgium continues to contribute evidence that lack of circumcision
and presence of other STDs are linked with increased HIV prevalence.
She performed a large cross-sectional analysis of factors associated
with having HIV in four African towns, two of known high HIV preva-
lence and two with a low, stable HIV prevalence. In each town, 1,000
men and 1,000 women were interviewed and examined.
In Yaounde, Cameroon and Cotonou, Benin, two towns with an adult male
HIV prevalence of about 4%, nearly all men studied (>99%) were cir-
cumcised. In Kisumu, Kenya, with an adult male HIV prevalence near
20%, just 28% of men were circumcised. In Ndola, Zambia, where the
adult male prevalence of HIV infection is around 23%, the circumci-
sion rate was only 9%. In Kisumu, 10% of HIV infections occurred in
circumcised men and lack of circumcision emerged as a strong inde-
pendent predictive factor for acquiring HIV infection. Fully 25% of
Ndola's circumcised men were HIV-positive. The protective effect of
circumcision could not be ascertained in Ndola because too few cir-
cumcised men were available to achieve statistical precision. The
overall survey also found positive associations with HIV infection
for alcohol use, genital herpes and a history of sexually transmitted
disease. Interestingly, no cases of syphilis were observed in any
circumcised men.
Buve concluded that male circumcision is protective against HIV in-
fection, although the magnitude of the effect may differ between
populations. One risk to this intervention, she warns, is that newly
circumcised men may believe they are now HIV-proof and discontinue
their use of condoms. Lower Risk for Muslims Ronald Gray of Johns
Hopkins University in Baltimore presented findings from observational
studies of HIV incidence in a cohort of 5,507 HIV-negative men and
studies of smaller numbers of sero-discordant couples in Rakai,
Uganda. The rate of new infections observed in these cohorts between
1994 and 1998 was 1.1 per 100 person years (py) among circumcised men
and 1.8 per 100 py among uncircumcised men. Circumcision before pu-
berty was associated with reduced HIV incidence. The rate of infec-
tion for men who had been circumcised before puberty was 0.9 per 100
py compared to 1.5 per 100 py for those circumcised when older than
12 years. The benefit of postpubertal circumcision in this study was
not statistically significant.
Nearly all (over 99%) of the 737 Muslim men in this cohort were cir-
cumcised; only 3.7% of non-Muslims were circumcised. Additionally,
all Muslims were circumcised before puberty whereas only 48% of non-
Muslims were. Overall, HIV incidence was reduced by -0.9 per 100 py
among Muslims compared to uncircumcised non-Muslims in Rakai. Gray
observed that certain Muslim behaviors such as non-use of alcohol
might confer additional protection. Alcohol use has been highly asso-
ciated with paying for sex, non-use and misuse of condoms and in-
creased risk-taking. Another possibly protective Muslim practice is
polygamous marriage, which creates closed sexual networks for men
with multiple wives.
An understudied Muslim behavior that may also help reduce transmis-
sion is postcoital genital washing, routinely performed prior to
prayer. Gray believes that the cumulative effect of these additional
protective factors may have contributed to an observed reduction of
HIV infection by -0.5 per 100 py among Muslim men compared to circum-
cised non-Muslims. Among the discordant couples with HIV-negative
males in Rakai, no HIV infections occurred in 50 circumcised men,
whereas new infections occurred in 16.7 per 100 py among uncircum-
cised men. For couples with HIV-positive men, there was no difference
in the rate of transmission between circumcised and uncircumcised men
for those with viral loads over 50,000 copies/mL (25 per 100 py).
However, among men with viral loads less than 50,000 copies/mL, there
were no observed transmissions of HIV from circumcised men to their
partners compared to 9.6 per 100 py transmissions from uncircumcised
men.
David Serwadda, of Makerere University in Kampala, Uganda analyzed
the Rakai incidence data to estimate the potential impact of prophy-
lactic circumcision of HIV-negative men on a population-wide basis.
This issue gains urgency because of the principle that any interven-
tion resulting in a reduction of HIV incidence among men will lead to
a lower prevalence among women and ultimately have a damping effect
on the pace of the epidemic. Based on the Rakai incidence data, Ser-
wadda proposed a potential reduction of HIV acquisition ranging be-
tween 11% and 22%. Unfortunately, observational studies such as these
do not allow conclusions about the protective value of circumcision
to be generalized to other populations. This raises the question of
whether a randomized trial of circumcision is warranted. While prepu-
bertal circumcision may afford better protection, it would require
two decades to investigate that intervention. Serwadda thinks that
trials of adult male circumcision may be feasible in highly exposed
populations where smaller protective effects might be observed. If
male circumcision is a potentially effective intervention that de-
serves a controlled trial, then current attitudes and practices need
to be studied and described.
It is quite reasonable to ask, as the next two presenters did, how
many men would be willing to undergo an invasive and irreversible op-
eration on what respondents often called "the site of their manhood."
Attitudes toward Circumcision
Insight into this question was offered by reports on knowledge and
beliefs about circumcision in two populations: the residents of Car-
letonville, South Africa, where circumcision is fairly common among
various ethnic and cultural groups, and the Luo people of Kenya, who
do not routinely practice circumcision. South African researcher
Reathe Taljaard explored attitudes toward male circumcision in the
heavily HIV-affected region of Carletonville, where he found widely
varying prevalence and ages at circumcision. Initiation into the tra-
ditional culture, whether Zulu, Pedi or Xhosa, is a rite of passage
to manhood for many boys during their teenage years. Young men at
this transitional stage may spend several weeks sequestered at an
initiation school learning about traditional life and values.
In some cultures, this ritual passage has included circumcision, per-
formed by the traditional circumciser, to give evidence that the boy
has become a man. In recent years though, young men have sought cir-
cumcision by local medical practitioners as an alternative to the
traditional cutting. This is true both for boys who go on to initia-
tion school as well as for those who prefer to attain manhood without
benefit of ritual. Fear of pain and stories of "cutting short" have
driven this trend. Indeed, on the second day of the AIDS Conference,
a news brief appeared in the Durban Daily News about a traditional
circumciser charged with culpable homicide in the death of a young
initiate after a botched Xhosa ceremony in the Eastern Cape.
Taljaard examined general beliefs about circumcision among women as
well as men, since wives often made the clinic appointments for their
husbands to have the procedure. Among various common beliefs were
ideas that a circumcised penis was associated with cleanliness, did
not gather dirt, did not suffer damage when entering a virgin, was
immune to HIV (but not STDs), and was easier to aim. Other beliefs
were that circumcision enhanced sexual performance, increased the
size of the penis and brought respect. Some thought that it was bad
luck not to be circumcised; some said that Westerners learned circum-
cision from Africans.
Robert Bailey of the University of Chicago interviewed adult Luo men
and women from non-urban areas of the Nyanza province of Kenya con-
cerning the acceptability of male circumcision. This is an area where
circumcision is not traditionally practiced, and 90% of men are not
circumcised. The prevalence of HIV is estimated at 27 to 35% among
women in the area. Despite the low traditional prevalence of circum-
cision, there was widespread belief that circumcised men were cleaner
and were less likely to contract HIV or STDs. The belief that circum-
cised men and their partners derived greater enjoyment from sex was
widespread. Given the choice, 60% of men said they would prefer to be
circumcised, and 74% of men and 88% of women would have their son
circumcised.
Lack of Training and Supplies
Bailey and colleagues also interviewed regional medical practitioners
about their knowledge and experience with circumcision. They also in-
ventoried clinic supplies and instruments necessary for performing
the operation. Only 39% of clinicians were circumcised themselves,
and 40% had never performed a circumcision. Knowledge of the risks,
benefits and proper procedures were low, and only one of eight clin-
ics inventoried had the proper supplies and instruments. Bailey also
reported that knowledge of the principle of informed consent was
lacking. These results suggest that the obstacle to a controlled
trial of prophylactic male circumcision may not be patient acceptance
so much as a lack of training, experience and ethical guidance for
performing the research in affected areas.
References
Bailey R, et al. Trial Interventions Introducing Male Circumcision to
Reduce HIV/STD Infections in Nyanza Province, Kenya: Baseline Re-
sults. XIII International AIDS Conference, Durban, South Africa. July
9-14 2000; Abstract MoOrC196.
Buve A, et al. Male Circumcision and HIV Spread in Sub-Saharan Af-
rica. XIII International AIDS Conference. Durban, South Africa. July
9-14 2000 Abstract MoOrC192.
Circumcision Information and Resource Pages.- (www.cirp.org
<http://www.cirp.org>)
Gray R, et al. HIV Incidence Associated with Male Circumcision in a
Population-Based Cohort, and HIV Acquisition/Transmission Associated
with Circumcision and Viral Load in Discordant Couples: Rakai,
Uganda. XIII International AIDS Conference. Durban, South Africa.
July 9-14 2000; Abstract MoOrC193.
Serwadda D, et al. Potential Efficacy of Male Circumcision for HIV
Prevention in Rakai, Uganda. XIII International AIDS Conference. Dur-
ban, South Africa. July 9-14 2000; Abstract MoOrC194.
Taljaard R, et al. Cutting It Fine: Male Circumcision Practices and
the Transmission of STDs in Carletonville. XIII International AIDS
Conference, Durban, South Africa. July 9-14 2000; Abstract MoOrC195.
000810 AM000802
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Cecilia Snyder
mailto:[email protected]
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