16 Features
Tradition, transmission, int Nikki Bozinoff and Jamie Lundine unpack the implications of male circumcision as potential HIV prevention
“I
t is more than a cut. It is a lot of things really,” offers Stanley Riamit, a Kenyan completing his master’s in Anthropology at McGill. We’re chatting about male circumcision over coffee. Yes, circumcision, the surgical procedure which removes all or part of the penile foreskin. Beside Riamit sits Philip Osano, grinning knowingly. He is also Kenyan, and is completing his PhD in Geography at McGill. Riamit is a member of the Maasai community, a traditionally circumcising group, while Osano is of the Luo ethnic group, a traditionally non-circumcising community. Circumcision is a big deal in Kenya these days. Raila Odinga, the country’s prime minister, has publicly announced that he is circumcised. A host of Luo leaders have done the same, and clinics performing the service are reportedly drawing lineups. Why the sudden fanfare about a simple surgical procedure? Recent studies have proven that circumcised men have a decreased risk of acquiring HIV through penile-vaginal sex. Studies have yet to show whether male circumcision prevents the spread of HIV from men to their female partners, or if it is effective in reducing risk of infection during anal sex. According to UNAIDS, between 7.1 and 8.5 per cent of adults aged 15 to 49 in Kenya are HIV-positive. As Osano
describes, “Any strategy that is going to help you avoid HIV/AIDS, to reduce your risk, is going to be embraced.”
A
s early as 1989, just six years after AIDS was first identified, researchers identified the link between populations in Africa with high HIV prevalence and low rates of circumcision. But a simple correlation does not a public health intervention make. Like so many headlines that pass through the pages of epidemiological journals, this one was noted, and then dismissed as impractical. Throughout the 1990s, observational studies continued to suggest that traditionally circumcising populations had a lower risk of acquiring HIV, but numerous confounding variables troubled these findings. What if there were other cultural norms placing men in these groups at a lower risk of HIV infection? Still, researchers argued that if male circumcision really did have a protective effect, the implications could be huge – particularly in sub-Saharan African countries where there were low rates of male circumcision, and high prevalence of HIV infection. Clearly, more serious research was necessary. Between 2002 and 2003, three randomized control trials began in South Africa, Uganda, and Kenya. In each trial, consenting,
healthy, HIV-negative adult men were randomly assigned to receive circumcision immediately or to wait until the end of the trial to undergo the procedure. Both groups were then followed to assess HIV incidence. All participants were counselled in HIV prevention and riskreduction techniques, and were provided with condoms. The results of the trials were clear: The South African trial showed that HIV acquisition was reduced by 61 per cent in men who became circumcised compared with men who remained uncircumcised; 53 per cent in the Kenyan trial; and 51 per cent in the Ugandan trial. While international agencies had previously dragged their feet, citing the logistical and ethical problems of endorsing male circumcision as a means of prevention, evidence from the three randomized control trial helped make male circumcision a matter of human rights. In March 2007, the World Health Organization (WHO) and UNAIDS convened a consultation to examine the results of the aforementioned trials, and additional scientific evidence. The consultation reaffirmed the results of the trials – male circumcision reduces HIV transmission from women to men. In a UNAIDS and WHO document produced after the consultation, the participants of the consultation declared that “a human rights-based approach to the development or expansion of male circumcision services requires measures that ensure that
the procedure can be carried out safely, under conditions of informed consent, and without coercion or discrimination.” With UNAIDS and WHO recognizing the trials’ results, the stage was set for implementing circumcision as a preventative measure.
R
obert Bailey is a professor of epidemiology at the University of Illinois at Chicago and one of the principal authors of the Kenyan randomized control trial study. As far as he is concerned, there is overwhelming evidence suggesting that circumcision should be implemented as a means of prevention of female-tomale transmission in areas of high HIV prevalence and low circumcision. “I am completely convinced that the trials certainly show that circumcision reduces a man’s risk [of acquiring HIV]. Now the challenge is to see if it is actually going to be effective in rural settings,” Bailey says. But many aren’t convinced that enough research has been done. Vinh-Kim Nguyen, Associate Professor of Social Medicine at the University of Montreal, and an HIV physician and researcher, argues that since circumcision must be made available to everyone, and not just those men who are HIV negative, more research needs to be done on circumcision’s effect on HIV-positive men. In particular, he notes a study presented at the 2008 Conference on Retroviruses and Opportunistic Infections. “[It] suggests that HIV-positive men take longer to heal and therefore if they’re circumcised, they actually have a greater chance of transmitting HIV to their partners,” Nguyen says. Nguyen cites concerns over how the intervention will play out. “We don’t have enough answers about what is going to happen when you do this in the real world, outside of a standardized control trial…. The devil is in the details,” Nguyen says.
Sasha Plotnikova / The McGill Daily