Recent studies in Africa have suggested that male circumcision can halve the risk of HIV infection and a WHO meeting declared that male circumcision should now be recognised as an important intervention to reduce the risk of HIV. Mariette Correa assesses the evidence and the implications to public health and cultural concerns if this intervention is widely implemented in India

Since mid-2006, and especially during the XVI World AIDS Conference in Toronto in August 2006, there has been much rejoicing at the suggestion that male circumcision could keep HIV infection at bay. Male circumcision received fresh impetus with the results of recent studies in Africa that have shown that circumcision can reduce HIV infection by about 50%.

The trial in Kisumu, Kenya, of 2,784 HIV-negative men showed a 53% reduction of HIV acquisition in circumcised men relative to uncircumcised men, while a trial of 4,996 HIV-negative men in Rakai, Uganda, showed that HIV acquisition was reduced by 48% in circumcised men. In 2006, PLoS Medicine published a report from a third trial in South Africa which also supports the claim that male circumcision is effective in reducing HIV transmission to men.

Following the results of these studies, WHO/UNAIDS convened an expert meeting in March 2007 on male circumcision for HIV prevention. Experts at the meeting recommended that male circumcision now be recognised "as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men" especially in countries with high rates of heterosexual HIV infection and low rates of male circumcision.

But do we really have reason to rejoice? There are still too many questions left unanswered and too many ethical and other issues that beg clarity before we can discuss the viability of promoting male circumcision as a national HIV prevention strategy.

Mixed results

In the three much touted studies, a lot of infections occurred even in circumcised men who used condoms always. In the Rakai study, 16 (of 67) incident infections occurred in men who had not had sex or who always used a condom. In the South Africa study, 23 (of 69) incident infections occurred in men who reported no unprotected sex during the observation period. It is unclear what non-sexual exposures the men in the trial had to HIV, such as injections or tatoos that could have

Other studies have shown mixed findings; while some have found that circumcised adults (both men and women) were less likely to be HIV infected than uncircumcised adults, a study by Brewer et al found that circumcised male and female virgins and adolescents in Kenya, Lesotho, and Tanzania are more likely to be infected with HIV than their uncircumcised counterparts. (Brewer D D, Potterat J J, Roberts Jr J M, ‘Male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania’, 2007).

It is also known that there are substantial reductions in genital symptoms following circumcision. As a result, it is possible that circumcised men are less likely to seek treatment for genital symptoms and consequently receive fewer blood exposures to HIV from unhygienic care, so typical in developing countries.

The three African studies claim that there is approximately 50% reduction in HIV transmission. Could this 50% reduction in risk following an irreversible procedure justify national strategies promoting male circumcision?

There is no clear correlation between countries that have high HIV prevalence and high circumcision prevalence. What is going on is not so clear. Data from Demographic and Health Survey(http://www.measuredhs.com/countries/start.cfm) show that circumcised men in six of 10 African countries (Ghana, Cameroon, Tanzania, Lesotho, Malawi, Rwanda) have higher HIV prevalence than uncircumcised men.

Gender concerns

Will male circumcision make women less or more vulnerable to HIV infection? There is no evidence that male circumcision would protect women. One cannot find evidence of increased male circumcision and reduced HIV in women. We do not know the impact of male circumcision on sexual transmission from HIV-infected men to women, the impact of male circumcision on the health of women for reasons other than HIV transmission, and the protective benefit of circumcision among men who have sex with men. We do know that male circumcision does not reduce viral loads and would not reduce infectivity to the female partner. Further, the combination of dry sex and circumcision appears to sharply increase the risk of male-to-female transmission of HIV.

Male circumcision removes nerves from the penis and causes significant loss of sexual sensitivity and function. The desensitisation of the penis is likely to make men less willing to use condoms. A programme of mass male circumcision may very likely reduce condom usage and worsen the epidemic.

There is a good chance that men who undergo circumcision will have low risk perception of acquiring and passing on HIV. This is likely to further reduce women's ability to negotiate condom use with their circumcised male partners. When would reduced condom use negate the protective effects of male circumcision?

Unsafe health care and weak healthcare systems

The clinical trials were done in medically controlled conditions. Dr Anthony S Frauci, director of the National Institute of Allergy and Infectious Diseases (NIAID) emphasised that the trials demonstrated "that medical circumcision is safe and effective when the procedure is performed by medically trained professionals and when patients receive appropriate care during the healing period following surgery." (http://www.healthnews-stat.com/?id=257&keys;=HIV-circumcision-NIH)

Experts at the WHO/UNAIDS consultation stated, "The risks involved in male circumcision are generally low [sic], but can be serious if circumcision is undertaken in unhygienic settings by poorly trained providers or with inadequate instruments. Wherever male circumcision services are offered, therefore, training and certification of providers, as well as careful monitoring and evaluation of programmes, will be necessary to ensure that these meet their objectives and that quality services are provided safely in sanitary settings, with adequate equipment and with appropriate counselling and other services."

Is this achievable in Africa and Asia, where much of health care is unsafe? It is more likely than not, that circumcisions will be performed in unsafe and unhygienic conditions, leading to increased risks of transmission of HIV and other blood-borne infections, apart from creating other health complications. Besides, the already overburdened health systems in these countries will not be able to take on the task of circumcising the numbers of men required in a national scale-up. This will obviously mean dependence on private providers, traditional healers etc. Even in clinical settings plagued by poor infection control, medical circumcision will not be any guarantee for hygienic care.

In such a scenario, what kinds of pre- and post-surgical support will be in place for men who undergo circumcision? In the past several months, requests for male circumcision have tripled in Nyanza province of western Kenya following the results of the circumcision trials, placing a burden on the weak health system. Will India’s health care systems be able to take on the responsibility of a mass circumcision programme? Will male circumcision services for HIV prevention unduly disrupt other health care programmes, including other HIV/AIDS interventions, or detract from resources better used elsewhere?

With the inadequate counselling facilities in India, will adequate measures be taken to ensure that informed consent is given by men who understand both the risks and benefits of circumcision? Will men be told about the physical risks, the sexual risks, and that circumcision protects against only some types of sexually transmitted infections?

Cultural appropriateness

How do communities that do not usually practise circumcision accept a practice that is largely culturally determined? Should circumcision be offered at birth or before sexual debut in such a context?

In a Hindu majority country like India, where circumcision is not practised much, the circumcision theory hasn't received much encouragement. With AIDS still not recognised as a serious problem by the majority of Indians, it may be difficult to translate the ‘success’ of the circumcision trials into intervention strategies that do not give assurance of complete protection. Being circumcised or not is an integral part of the religious identity of many communities in India. Can parents of the majority of Indians be convinced to re-define their identity for a remotely perceived hypothetical situation in the distant future where their child may be protected from a virus?

Still, if circumcision prevents HIV infection, should NACO provide access to the procedure free or at minimal cost making the range of HIV prevention options available to people?

Other pertinent concerns

Even if it is accepted that circumcision reduces men’s risk of acquiring HIV, there has to be careful education around this message in case people develop a false sense of security and wrongly assume that if they are circumcised, they will be immune from HIV. There is also a need to communicate the relative benefits of the procedure as well as the small but significant risks.

Before contemplating a scale-up of circumcision facilities, we need to know the benefits for people living in HIV discordant relationships of whether penal hygiene reduces HIV transmission rates similar to the levels of male circumcision, and the risk of complications from the procedure performed in various settings. We also need to keep in mind cultural and human rights considerations, and weigh the balance of the rights of the child versus public health benefit.

In conclusion, national policymakers must guard against being overwhelmed by the promotion of male circumcision and must receive these new studies with caution. We need to be clear that the ideal and well-resourced conditions of a randomised trial cannot be replicated in other settings, especially in resource poor countries like India.

(Mariette Correa is an independent consultant who has been involved in HIV/AIDS programming for NGOs in Goa and South Asia)

Infochange News & Features, March 2008