AFRICA: Questions re HIV/circumcision link

African voices are beginning to question the widely and uncritically reported results of the Kenyan and Ugandan studies touting circumcision as an effective method against HIV infection.

Dr. Joseph Matare, HIV/AIDS Medical Officer for Namibia, recently wrote in The Zimdaily Weekender, “My opinion is that we should stick to proven methods of preventing HIV for now. Mutual fidelity and abstinence are the gold standards. Stay clear of persons whose status you do not know (assuming you know your own!). If you have to have any sexual relations with the person (s), the condom used correctly will reduce your risk significantly.”

Dr. Matare, writing in an objective yet skeptical tone, made several cogent observations.

One would want to ask the following question: How would they know circumcision does work or not if the men were NOT exposed to HIV? That would mean the men had to be “encouraged” to expose themselves to an HIV risk for researchers to be able to compare the HIV incidence (new HIV cases) in the two groups.

Suppose the circumcised group, because they had undergone a surgical procedure, which may take time to heal, prolonged their delay to return to active sex.

This group may also have used condoms more consistently for fear of HIV transmission because they still had potential unhealed wounds.

The HIV status of the women each of the individuals who had or did not have the circumcision had “unprotected” sex with was not known. Therefore, suppose by chance the uncircumcised man were unfortunate to have been in contact with more HIV positive women, and the circumcised group having less infected women, that would skew the results.

Also we do not know which of the two groups used more of the available known method of HIV prevention: the male condom.

These are some of the many questions that were or could be asked in reviewing this study. There is so much controversy about that and the jury is still out (there is no conclusion yet) on the effectiveness of circumcision as an HIV prevention method.

Dr. Matare’s comments add to the growing chorus from the non-circumcising world questioning studies carried out and funded by researchers from circumcising nations under dubious ethics.

Complete text of the article after the jump.

Male Circumcision and HIV Prevention – The Great Controversy

In the quest to reverse the unabating HIV epidemic, various strategies are being experimented with and researched to complement existing methods. 

Dr Joseph Matare – HIV/AIDS Medical Officer – Namibia

Already promising results indicate microbicides, to be used by women, may have a definite impact in preventing heterosexual HIV transmission.

Women will have an opportunity to take total control of the prevention effort in the frequent circumstances where men may decide not to use the condom.

Some of you may have heard of male circumcision being touted as a possible method to prevent HIV transmission, especially for regions and countries of sub-Saharan Africa

The suggestion has been widely accepted in some quarters of the scientific community as a potential effective public health approach to help tame the epidemic in the AIDS belt that spans from East Africa through central Africa and gets pretty huge in southern Africa (Malawi, Zimbabwe, Zambia, South Africa, Namibia, Botswana, Swaziland).

On the contrary, other sections of the scientific community have been outraged by the sudden interest in the absence of a skin on the men’s privates as a “revolutionary” intervention.

And studies have been conducted in what other commentators have described as somewhat “dubious” circumstances to support the hypothesis that circumcision works. Other studies, on the contrary, have concluded that circumcision confers no benefit as an HIV prevention strategy.

One may want to ask why suddenly people now think circumcision could be the answer. This is because people looked at the epidemiology of HIV in terms of the distribution of the HIV epidemic in the world and began to hypothesize the possible confounding with local/regional social cultural practices.

Therefore, there could be something different about North Africa and most of West Africa where the HIV prevalence is very low compared to the AIDS belt.

What they found prominently different about these regions is not only religious persuasions but the practice of circumcision (which is also present in some non-Moslem communities) of sub-Saharan Africa.

Immediately someone had the eureka experience that this then meant circumcision had a preventative effect on HIV transmission, which infers that if men were wantonly circumcised without any change in their sexual behaviour (that had hitherto put them at risk) they would have this risk markedly reduced.

Then studies (called randomized controlled trials) were conducted to investigate the truthfulness of this hypothesis (assumption).

As expected, the studies were beset with ethical dilemmas. For the circumcision to be proven whether it works or not, sexually active men who were HIV negative at that time would have to agree to be randomly selected (to reduce bias) into two groups. One group would be circumcised, and the other would not.

One would want to ask the following question: How would they know circumcision does work or not if the men were NOT exposed to HIV? That would mean the men had to be “encouraged” to expose themselves to an HIV risk for researchers to be able to compare the HIV incidence (new HIV cases) in the two groups.

If circumcision really works, that is, it is protective, it is expected that the HIV incidence rate in the circumcised group would have to be much lower than the incidence rate in the uncircumcised group after a certain period of the follow-up.

A study that was done suddenly showed that the group that was circumcised had reduced HIV incidence compared to the uncircumcised group meaning circumcision had an effect. In fact, the study had to be suspended because the evidence was overwhelming!!!!

The researchers stated that they had advised both groups to consistently use condoms (a proven HIV prevention method!). Suppose the circumcised group, because they had undergone a surgical procedure, which may take time to heal, prolonged their delay to return to active sex.

This group may also have used condoms more consistently for fear of HIV transmission because they still had potential unhealed wounds. The HIV status of the women each of the individuals who had or did not have the circumcision had “unprotected” sex with was not known.

Therefore, suppose by chance the uncircumcised man were unfortunate to have been in contact with more HIV positive women, and the circumcised group having less infected women, that would skew the results.

Also we do not know which of the two groups used more of the available known method of HIV prevention: the male condom. These are some of the many questions that were or could be asked in reviewing this study. There is so much controversy about that and the jury is still out (there is no conclusion yet) on the effectiveness of circumcision as an HIV prevention method.

My opinion is that we should stick to proven methods of preventing HIV for now. Mutual fidelity and abstinence are the gold standards.

Stay clear of persons whose status you do not know (assuming you know your own!). If you have to have any sexual relations with the person (s), the condom used correctly will reduce your risk significantly.

In conclusion, it is still premature to have male circumcision adopted as a public health approach to prevent sexual HIV transmission.

If you should seriously consider circumcision for the sake of HIV prevention, I strongly suggest one should circumcise his wayward and known risky sexual behaviors, and one would not need to go “under a knife” to make this possible.

Reference

Matare, Joseph, MD. Male Circumcision and HIV Prevention – The Great Controversy. The Zimdaily Weekender. January 29, 2007.

http://zimdaily.com/news/129/ARTICLE/1260/2007-01-29.htmlAfrci

This entry was posted in Africa and tagged , , , , , , , . Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s