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Male Circumcision and HIV Prevention

Abby Hannifan

October 5, 2009

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What the world is saying…

 

Researchers have been systematically exploring male circumcision as a means of HIV-transmission prevention in heterosexual males for a little more than a decade. Statistical evidence demonstrates that male circumcision (MC) could be an integral element in the comprehensive list of prevention techniques meant to thwart the spread of HIV/AIDS. Advocates for male circumcision include international aid agencies, public health experts, and HIV/AIDS charities. Opponents are typically those who believe that male circumcision is a human rights issue, or those who are skeptical about the procedure’s cost-effectiveness and ability to be implemented successfully. This review will detail the characteristics and breadth of HIV/AIDS; the rationale behind another prevention technique; a history of male circumcision and claims made about its effectiveness in preventing HIV transmission; the limitations and drawbacks of the procedure; and a recommendation for the intervention’s implementation.

 

The World Health Organization (WHO) states, “There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. (http://www.who.int/hiv/topics/malecircumcision/en/)

 

Auvert et al. (2006, page 5) asserted, “MC could avert 5.7 million new cases and 3.0 million deaths, while reducing the number of people infected with HIV in 2025 by 4.1 million.

 

A 2007 online United Nations Children’s Fund (UNICEF) newsletter mentioned, “Male circumcision is the most compelling evidence-based prevention strategy to emerge since the finding that antiretroviral medication can reduce mother-to-child transmission of HIV.”

(http://www.who.int/hiv/pub/malecircumcision/africa_opportunity/en/index.html)

 

What is HIV/AIDS? 

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Human Immunodeficiency Virus (HIV) is the precursor to Acquired Immune Deficiency Syndrome (AIDS). It functions primarily by attacking CD4+ cells (also called helper T-cells)—white blood cells that serve as important components of a healthy, functioning immune system. HIV takes over these CD4+ cells and utilizes them to replicate prolifically. As the virus reproduces, it damages or kills the CD4+ cells, thus allowing opportunistic infections (like tuberculosis and pneumonia) to take advantage of the debilitated immune system. Once an HIV-positive individual has developed at least one of 21 identified opportunistic infections and has a CD4+ count lower than 200 cells per cubic millimeter of blood, the person is said to have full-blown AIDS (http://www.thewellproject.org/en_US/HIV_The_Basics/What_is_HIV.jsp).

 

There are several stages in the development of AIDS. During the primary HIV infection stage, a person’s HIV status converts from negative to positive (sero-conversion) four to eight weeks after initial viral transmission. At this time, the individual may experience flu-like symptoms. If the virus is caught during this stage, anti-retroviral therapy (ART) is encouraged to diminish viral load, thus strengthening the immune system. During the asymptomatic latent phase, the HIV-positive individual may not display any symptoms for many years, even though the virus continues diminishing the immune system’s capacity. Next, more telltale symptoms of HIV (like skin rashes, weight loss, and fevers) appear in the minor symptomatic phase of HIV disease. These symptoms worsen in the major symptomatic phase of HIV infection and opportunistic diseases. Usually after about 18 months, the virus develops into full-blown AIDS in the severe symptomatic phase. (http://www.health24.com/medical/Condition_centres/777-792-814-1756,22216.asp)

 

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The body fluids through which HIV can be transmitted include blood (pertinent to injection drug users who share contaminated needles and, when AIDS first emerged, hemophiliacs who received frequent blood transfusions); semen (even “pre-cum”); vaginal secretions (applicable to sexual intercourse and mother-to-child transmission during the birthing process); and breast milk. Because HIV-positive individuals may not have any physical indication of the presence of HIV during the early stages, they may unknowingly transmit the virus to others. This is why awareness, prevention, and testing campaigns are imperative. (http://www.thewellproject.org/en_US/HIV_The_Basics/HIV_Transmission.jsp)

 

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There are many proposed and widely accepted HIV-transmission prevention techniques and strategies. These include, but are not limited to, abstaining from sexual contact; limiting the number of sexual partners and remaining monogamous while in a relationship; using condoms consistently and correctly for every sexual encounter; sterilizing needles or participating in a needle exchange program; educating children about safe sex practices and encouraging a delay in first sexual encounter; taking anti-retroviral drugs during pregnancy if HIV-positive; and practicing safer infant feeding once the baby is born. HIV prevention efforts can also be facilitated by larger structural considerations, such as stigma and discrimination reduction; political leadership in tackling HIV education, prevention, and treatment; cooperation among community organizations, non-profits, governmental bodies, and international aid agencies to engage in open discussion about the implications of HIV/AIDS; and increased access to health care for developing nations. (http://www.avert.org/prevent-hiv.htm)

 

The breadth of HIV/AIDS: Why is there so much clamor on the web?

 

Since 1981, AIDS has caused 25 million deaths (http://www.avert.org/worldstats.htm). In 2007 alone, approximately 30.8 million adults and two million children were living with HIV. Also in 2007, 2 million people died due to AIDS, and the incidence was 2.7 million infections (http://www.avert.org/worlstatinfo.htm). Due to lack of resources and health infrastructure, widespread poverty, and insufficient emphasis on prevention and treatment, the developing world constitutes 95 percent of the global infected population. Only 31 percent of these people, however, have access to life-saving AIDS drugs. Sub-Saharan Africa has been especially hard-hit, accounting for about 67 percent of the worldwide HIV cases (http://www.avert.org/worldstats.htm). In addition to incapacitating individuals, high HIV prevalence puts a strain on an already overtaxed health care system, decreases overall life expectancy, and hinders economic development by decreasing worker productivity (http://www.avert.org/aafrica.htm).

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The rationale behind another prevention technique

 

Although the annual number of new infections is decreasing and the global percentage of individuals living with AIDS has stabilized, prevalence rates in some regions remain at an unacceptable level. The 2008 UNAIDS “Executive Summary: Report on the Global AIDS Epidemic” suggests that more comprehensive prevention programs are necessary in order to reduce HIV prevalence. The report warns against heavy reliance on treatment innovation, claiming that it often under-prioritizes investment in prevention. In other words, as treatment options become more accessible and effective, countries may begin to see HIV as less of a threat, which could cause governments to withdraw funding from prevention programs. Thus, it is the responsibility of governments and international aid agencies to ensure that prevention is kept a priority by developing, implementing, and evaluating evidence-based strategies to prevent HIV transmission.

 

Due to the fact that about two-thirds of new HIV infections are transmitted through heterosexual sex, a large emphasis is being placed on heterosexual sexual transmission prevention programs. The remaining one-third is almost evenly distributed amongst the other high-risk groups: injection drug users, babies with HIV-positive mothers, men who have sex with men, and health care personnel who frequently handle HIV-contaminated fluids (http://www.avert.org/worlstatinfo.htm). Although condoms are 90 percent effective in preventing HIV transmission, condom use might be limited in male-dominated societies in which women’s sexual rights are not well-acknowledged; cultural or religious settings in which contraception is uncommon, inappropriate, or unheard of; and sexual relationships in which one partner may not be aware of his or her positive HIV status. Therefore, alternative protective factors, like male circumcision (MC), should be explored (UNAIDS, “HIV Prevention”).

 

A brief history of male circumcision

 

The Centers for Disease Control and Prevention (CDC) define male circumcision as the surgical removal of all or some of the foreskin from the penis (http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm). According to the 2007 UNAIDS report “Male Circumcision: Global Trends and Determinants of Prevalence, Safety and Acceptability,” MC was traditionally performed for cultural or religious significance, dating back to ancient ceremonies among the Egyptians and Jews. Today, it is almost universally practiced by Jews and Muslims around the world. Many ethnic groups (primarily in sub-Saharan Africa, Southeast Asia, Central America, and aboriginal Australia) have a history of practicing MC for non-religious reasons. They treat it as a symbol of masculinity, a passageway into adulthood, proof of endurance, or a method of social cohesion for boys being circumcised at the same time. Currently, 30 percent of males 15 years of age and older are circumcised. (http://www.who.int/hiv/pub/malecircumcision/globaltrends/en/index.html)

 

Claims about effectiveness

 

As seen in three randomized controlled clinical trials, MC can reduce female-to-male HIV transmission by approximately 60 percent (http://www.who.int/hiv/topics/malecircumcision/en/). As with any trial, there is some degree of lack of total confidence in the generalizability of results. Before examining the downsides of MC and the opinions and skepticism of opponents, let’s examine and analyze the results from the three trials.

 

         1. Orange Farm, South Africa (outside Johannesburg)

Based on observational studies (mainly cross-sectional and prospective)—which found that men in East and Southern Africa, areas associated with a high HIV prevalence, are unlikely to be circumcised—Auvert et al. (2005) wanted to systematically test the effectiveness of MC in preventing female-to-male HIV transmission. To conduct this study, researchers offered the circumcision operation to young, sexually active, heterosexual, uncircumcised males in Orange Farm. They randomly assigned the 3,000 men who volunteered for the study to two groups—the “treatment group” was circumcised immediately, whereas the “control group” was told they would be circumcised after the study was complete (21 months later). Originally, researchers planned to test each man for HIV four times during the duration of the study. After 14 months, however, the number of new infections in the treatment group (20) was significantly lower than the number in the control group (49). The researchers concluded the study early and circumcised the remaining males, saying it would be unethical to continue with such convincing evidence. The researchers concluded that, because infections were 60 percent fewer in the treatment group, MC as a prevention measure against HIV could be highly beneficial, especially in areas where HIV rates are high and MC rates low.

 

2. Kisumu, Kenya

Similar to the Johannesburg study, this Kenyan study by Argot et al. (2007) identified around 3,000 eligible men who were willing to be randomly assigned to an intervention group (circumcision) or a control group (delayed circumcision). The study, which was supposed to last 24 months with 6 intermittent behavioral interviews, was stopped prematurely because researchers observed a 53 percent differential in HIV transmission between circumcised and uncircumcised males. The researchers concluded that MC should be “provided as expeditiously as possible” as part of a comprehensive intervention program in situations where it is appropriate, safe, affordable, and voluntary.

 

3. Rakai District, Uganda

The Uganda study by Bacon et al. (2007) was much larger, randomly assigning 5,000 men to an intervention and control group. Researchers planned to screen trial participants at 6-month, 12-month, and 24-month follow-up interviews, but like the other trials, the study ended early due to overwhelming evidence of a causal relationship between circumcision and HIV-transmission prevention. The study found that the incidence of HIV infection was 51 percent lower in the intervention group than in the control group. Thus, researchers concluded that MC should be encouraged as a prevention method in areas where public health authorities deem it beneficial.

 

Why the disproportion?

 

There are several reasons why circumcised and uncircumcised males are disproportionately susceptible to HIV acquisition through heterosexual sex. First, according to Schwartz (2007), the underside of the foreskin of the penis is less keratinized (making it less tough and more vulnerable to pathogenic infection) and has a higher concentration of target cells (which are conducive to the transmission of HIV). Because the foreskin of the penis is pulled down the shaft during sexual intercourse, these sensitive receptors are directly exposed to potentially contaminated vaginal secretions. Second, since the foreskin is more delicate than the rest of the penile tissue, it is more prone to lesions during intercourse. Viruses can enter the bloodstream via these epithelial disruptions (Short and Szabo, 2000). Third, research from Alanis and Lucidi (2004) suggests that the space (called the preputial sac) between the unretracted foreskin and the head of the penis could be the ideal environment for sexually transmitted diseases because it acts as an incubator, encouraging viral survival by creating a warm microclimate. Lastly, Hayes, Munabi, Thomas, and Weiss (2005) found that because circumcision protects against the transmission of other STDs, and because individuals with genital ulcers (caused by STDs such as genital herpes, chancroid, and syphilis) are at higher risk for HIV, uncircumcised men are at higher risk for both.

 

The links between circumcision and risk reduction of HIV transmission are obvious. Upon emergence of these findings, WHO released the studies’ results to experts—government representatives, scientists, and non-governmental organizations—for feedback. The experts responded by recommending that “countries with high prevalence, generalized heterosexual HIV epidemics that currently have low rates of male circumcision consider urgently scaling up access to male circumcision services” (http://www.who.int/mediacentre/news/releases/2007/pr10/en/index.html). According to AVERT, a UK-based international HIV/AIDS charity, “high prevalence” is defined as more than 3 percent for the general population. This expert statement confirms the suggestions spawned by observational studies (http://www.avert.org/circumcision-hiv.htm). For example, with sub-Saharan Africa demonstrating the lowest rates of MC in all of Africa (less than 20 percent in many countries) and the highest HIV prevalence rates in all of Africa, MC could prove to be a highly beneficial preventive measure, when coupled with a more comprehensive prevention package.

 

HIV rates compared to prevalence of male circumcision in sub-Saharan Africa

 

Adult (ages 15-49) prevalence

Male circumcision prevalence

Zambia

15.2%

 

Around 15%

Zimbabwe

15.3%

Botswana

23.9%

Namibia

15.3%

Malawi

11.9%

Around 21%

[From http://www.avert.org/subaadults.htm and “Male Circumcision: Global Trends and Determinants of Prevalence, Safety and Acceptability” (2007)]

 

Despite the substantially positive results of the three clinical trials and observational data summarized above, one needs to examine the limitations and drawbacks of MC before endorsing it as a global prevention method.

 

Limitations & Drawbacks

 

Limitations

First, according to the UNAIDS publication “New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications” (2007), MC has to be accepted by the inhabitants of the region in which the intervention will be attempted in order to be effective. If it is not supported for religious, cultural, or other reasons (distrust of the medical profession, fear of pain or incapacitation after surgery), there is little likelihood it will be effective. Second, as the expert panelists recommended, little public health benefit will result from promoting MC in the general population if the setting has a low HIV prevalence, or if HIV infection rates affect specific high-risk groups like injection drug users, men who have sex with men (MSM), or sex workers. This limitation is related to cost-effectiveness. In regions like sub-Saharan Africa, providing for male circumcisions as a preventive measure against HIV would yield high net savings in relation to the cost of treatment for HIV. This same effect would not be as dramatic in countries where heterosexual sex is not one of the most prominent modes of transmission. Third, MC only works to prevent HIV transmission from female-to-male. No evidence has been shown that MC helps in preventing HIV transmission from male-to-female. Fourth, there is still considerable debate as to how quality circumcision services will be made available to the public. Lastly, male circumcision is not a magic bullet. It is not nearly as effective a measure against HIV transmission if it is not coupled with a more comprehensive prevention package, including HIV testing and counseling services; treatment for sexually transmitted infections (STIs); promotion of safer sexual practices; and the accessibility and proper and consistent use of male and/or female condoms. (http://www.who.int/mediacentre/news/releases/2007/pr10/en/index.html)

 

Drawbacks

First, because MC is a medical procedure, it carries with it safety hazards. For the procedure to be performed properly, considerable resources and decent health infrastructure are required. This is an issue that needs to be addressed if the under-resourced developing world, particularly Africa, is staged to benefit most from adopting MC as an HIV prevention tactic. If improperly performed, it can result in excessive bleeding or damage to the penis. Even if the procedure is completed successfully, the individual must comply with post-surgery stipulations (abstaining from sex for a few weeks). If not, the sensitive incision wounds could increase risk of HIV infection. Second, there is fear that widespread publication of the effectiveness of MC in preventing HIV transmission could result in more lax sexual practices (not wearing condoms, visiting prostitutes more often) among already circumcised men due to over-confidence in MC’s protective effects. Third, some cultures (in which circumcision is uncommon) and religions (Hinduism and Sikhism) oppose circumcision. Fourth, even if safe, sterile MC services are offered by trained staff, circumcision costs anywhere from $25 to $500 per person in Africa. Essentially, in such an impoverished continent, universal access is necessary to make any real progress in adopting MC as a prevention technique. Lastly, endorsing MC in countries where female genital mutilation is common could create double standard confusion (http://www.avert.org/circumcision-hiv.htm, http://www.who.int/hiv/pub/malecircumcision/globaltrends/en/index.html).

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Conclusion & Recommendation

 

Male circumcision as a means of preventing HIV transmission has advantages and disadvantages. As far as benefits go, MC has been found to reduce the risk of female-to-male HIV transmission to a considerable degree. It is a fairly simple procedure that, if done properly, requires little recovery time and minor discomfort. It could be exceptionally beneficial if endorsed and encouraged more aggressively by public health agencies in Africa (particularly sub-Saharan Africa), where heterosexual sex is the primary mode of transmission and MC rates are low. In an era in which HIV/AIDS rates remain at alarmingly high levels, any alternative prevention measure, when coupled with other effective prevention practices, could aid in the reduction of HIV/AIDS prevalence. There is an exigent need for governmental bodies, private NGOs, and local public health authorities to weigh these benefits with the potential limitations and detriments—primarily, these groups should analyze whether the success of clinical studies is applicable to their respective countries and cultural circumstances. This would require an investigation of the distribution of HIV prevalence among high-risk groups and any religious or cultural factors that would inhibit the intervention’s effectiveness. For those countries where MC is deemed an appropriate and beneficial intervention, though, governments should do everything possible to provide widespread access to the procedure, as it would produce high net savings (in money and in lives) in the end.

 

Pictures

  1. http://www.healthhype.com/knobbing-to-succeeding-procession-anti-retroviral-hiv-aids.html
  2. http://www.purselipsquarejaw.org/2009/09/visualisation-materialisation-and.php
  3. http://bioethics.com/?author=25&paged=2
  4. http://www.tpchd.org/page.php?id=179
  5. http://www.mapsorama.com/?s=aids
  6. http://codingnews.inhealthcare.com/hot-coding-topics/mind-your-modifiers-when-your-surgeon-works-with-others/
  7. http://commons.wikimedia.org/wiki/File:Religious_syms.png
  8. http://www.123rf.com/photo_3959889.html

 

 

References

 

Agot, K., Bailey, R. C., Campbell, R. T., Krieger, J. N., Maclean, I., Moses, S., et al. (February 24, 2007). Male

     circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The Lancet: 369.

 

Alanis, M. C., & Lucidi, R. S. (2004). Neonatal circumcision: A review of the world’s oldest and most controversial

     operation. Obstetrical and Gynecological Survey, 59(5), 379-395.

 

Auvert, B., de Zoysa, I., Dye, C., Getz, W. M., Gouws, E., Hankins, C., et al. (July 2006). The potential impact of male

     circumcision on HIV in sub-Saharan Africa. PLoS Medicine, 3(7): ed. 262.

 

Auvert, B., Lagarde, E., Puren, A., Sitta, R., Sobngwi-Tambekou, J., & Taljaard, D. (November 2005). Randomized,

     controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS

     Medicine: 2(11): ed. 298.

 

Bacon, M. C., Chaudhary, M. A., Chen, M. Z., Gray, R. H., Kiwanuka, N., Laeyendecker, O., et al. (February 24, 2007).

     Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet: 369.

 

Circumcision & HIV. (July 21, 2009). AVERT: AVERTing HIV and AIDS. Retrieved September 30, 2009, from

     http://www.avert.org/circumcision-hiv.htm

 

Executive Summary: Report on the Global AIDS Epidemic. (2008). UNAIDS, the Joint United Nations Programme on

     HIV/AIDS [Online publication]. Retrieved from WHO database,

     http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp

 

Hayes, R. J., Munabi, S. K., Thomas, S. L., & Weiss, H. A. (September 27, 2005). Male circumcision and risk of

     syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. British Medical Journal: Sexually

     Transmitted Infections, 82, 101-110.

 

HIV and AIDS in Africa. (September 28, 2009). AVERT: AVERTing HIV and AIDS. Retrieved September 30, 2009,

     from http://www.avert.org/aafrica.htm

 

HIV Prevention. (n.d.). UNAIDS, the Joint United Nations Programme on HIV/AIDS [Online publication]. Retrieved

     from Google database.

 

HIV Transmission. (June 2009). The Well Project. Retrieved September 30, 2009, from

     http://www.thewellproject.org/en_US/HIV_The_Basics/HIV_Transmission.jsp

 

Male Circumcision: Africa’s Unprecedented Opportunity. (August 2007). UNICEF Eastern and Southern Africa

     Regional Office (ESARO) [Online publication]. Retrieved from WHO database,

     http://www.who.int/hiv/pub/malecircumcision/africa_opportunity/en/index.html

 

Male Circumcision and Risk for HIV Transmission and Other Health Conditions: Implications for the United States.

     (February 7, 2008). Centers for Disease Control and Prevention. Retrieved from

     http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm

 

Male Circumcision for HIV Prevention. (2009). World Health Organization. Retrieved September 30, 2009, from

     http://www.who.int/hiv/topics/malecircumcision/en/

 

Male Circumcision: Global Trends and Determinants of Prevalence, Safety and Acceptability. (December 14, 2007).

     London School of Hygiene and Tropical Medicine, World Health Organization, and UNAIDS [Online publication].

     Retrieved from WHO database, http://www.who.int/hiv/pub/malecircumcision/globaltrends/en/index.html

 

New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. (March 2007).

     WHO/UNAIDS Technical Consultation [Online publication]. Retrieved from Google database.

 

Overview of HIV Prevention. (September 18, 2009). AVERT: AVERTing HIV and AIDS. Retrieved September 30, 2009,

     from http://www.avert.org/prevent-hiv.htm

 

Schwartz, Oliver. (March 2007). Langerhans cells lap up HIV-1. Nature Medicine, 13(3).

 

Short, R., & Szabo, R. (June 10, 2000). How does male circumcision protect against HIV infection? British Medical

     Journal, 320.

 

Symptoms and Phases of HIV Infection & AIDS. (July 20, 2004). Health24.com. Retrieved September 30, 2009, from

     http://www.health24.com/medical/Condition_centres/777-792-814-1756,22216.asp

 

What is HIV? (April 2009). The Well Project. Retrieved September 30, 2009, from

     http://www.thewellproject.org/en_US/HIV_The_Basics/What_is_HIV.jsp

 

WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention.

     (March 28, 2007). World Health Organization. Retrieved from

     http://www.who.int/mediacentre/news/releases/2007/pr10/en/index.html

 

Worldwide HIV & AIDS Statistics. (August 26, 2009). AVERT: AVERTing HIV and AIDS. Retrieved September 30,

     2009, from http://www.avert.org/worldstats.htm

 

Worldwide HIV & AIDS Statistics Commentary. (September 18, 2009). AVERT: AVERTing HIV and AIDS. Retrieved

     September 30, 2009, from http://www.avert.org/worlstatinfo.htm

 

 

 

 

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