Tradition, transmission, intervention

“It 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.”

As 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 risk-reduction 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.

Robert 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-to-male 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.

Arguably the most controversial aspect of this intervention is that it targets males, further perpetuating the gender divide of the HIV epidemic. Since women are often blamed for bringing the virus into a family, offering widespread protection to men and not women may exacerbate this situation.

As it stands, women overwhelmingly bear the burden of the HIV epidemic. They are both biologically and socially more vulnerable to HIV infection: the female anatomy simply puts women at greater risk, while economic dependence and lack of empowerment also contribute to HIV susceptibility. This is particularly evident in sub-Saharan Africa, where UNAIDS reports that women bear 60 per cent of HIV infections, compared to the global average of 50 per cent. Male circumcision is yet another preventative tool placed in men’s hands, that doesn’t address the gender disparity of the HIV epidemic.

The context in which researchers and policy-makers decide who and what gets funding has hindered the development of female-controlled prevention measures. Until recently, male researchers and decision-makers dominated the field of medical research, often causing female-centred research to be overlooked. Even today, research into female-controlled prevention is limited to microbicides – gels, creams, rings, or suppositories that could be inserted or applied by women before sexual intercourse and would protect against the transmission of HIV and other STIs. Difficulty in negotiating condom use, lack of access to male condoms, and the prohibitive high cost of female condoms all point to the urgent need to develop innovative prevention methods. According to the Global Campaign for Microbicides, 11 products are currently being tested for their efficacy in humans; however, as of yet, no product has proven effective. There is a critical need for more research and funding for such products – but there is a risk that attention on male circumcision may detract from research into microbicides or the development of other female-controlled interventions. Although Nguyen believes that male circumcision has not yet diverted research and money from female interventions, he stresses the need to consider this intervention as part of the larger social context in which HIV is transmitted.

“The fact that we have been unable to protect women has to do with the fact that we have been looking for these very individual-focused interventions without addressing the context that men have control, that men have power,” Nguyen says.

Bailey also acknowledges the possibility that male circumcision may propagate the gender divide.

“If men feel that they are protected, maybe they’ll be less likely to use condoms, and they might impose condom-free sex on their partners.… Circumcision cannot be a stand-alone surgical procedure. It has to be integrated with all of our other prevention strategies,” Bailey says.

On the other hand, Bailey and Nguyen both note that male circumcision may eventually benefit women. This is due to an effect termed “herd immunity,” normally used to describe the effects of widespread vaccination, whereby a population is protected as a result of the fact that many individuals have reduced likelihood of being infected. In this case, researchers predict that the protective effect of male circumcision cannot be 100 per cent, because the procedure only reduces risk, and does not eliminate it. Further, benefits are dependent on the rate of male circumcision in a given population. Because this intervention is only beginning to be offered, there is no “real world” evidence of how soon women will begin to see benefits. In their article “Understanding the Impact of Male Circumcision Interventions on the Spread of HIV in Southern Africa,” Hallet et al. use mathematical modelling to predict the reduction in the spread of HIV if the rate of male circumcision in a given population increases significantly. They conclude that over a 15 to 20-year period, with a population circumcision rate of 50 per cent, there would be an approximate 20 per cent reduction in HIV infection rates in the general population.

But as Bailey notes, male circumcision must not be viewed as a magic bullet, stand-alone solution, but as part of an integrated approach to HIV prevention. Osano expresses his fears of what will happen if male circumcision is not marketed along-side other prevention messages.

“My fear is that people might start seeing this as a panacea…particularly the young people. There needs to be a very clear educational program that tells people that this is just one of the ways to reduce your risk…. I think that’s not coming out clearly. I think the media has not picked this up; I think the leaders are not putting it across the way it should be put,” Osano says.

Yet male circumcision is being rolled out as a preventative measure in a very real way. Already, clinics in Kenya are providing the service, and other countries – Swaziland, Rwanda, and Zambia – are looking to offer circumcision in the near future.

Speaking about the intervention in western Kenya, Bailey cites the healthcare system’s lack of capacity as the main impediment to successful development of the procedure.

“One of the dangers is that if we put a lot of effort into circumcision, we are going to be reducing capacity for not only other HIV prevention but everything [else],” says Bailey.

Indeed, much of the debate surrounding male circumcision has been centred on the weakness of healthcare systems in resource-poor settings, and their limited ability to provide the service.

“You can get around these things, but it takes a lot of effort. It takes long-term investment in health systems,” Nguyen says.

Although Riamit and Osano express concern about limited healthcare capacity, they stress that engaging communities in dialogue is paramount. Circumcision is imbued with cultural meaning in many communities. For example, in communities that practice both male and female circumcision as a rite of passage, promoting one form while advocating against the other becomes problematic. Offering male circumcision as an intervention may in fact undermine the movement against female genital cutting. As a member of such a community, Riamit is particularly concerned with this dilemma.

“The challenge is we are saying ‘stop female genital mutilation’ but we are saying ‘circumcise men,’ and for rural communities, adding up these two things provides a challenge because now you will be forced to demonstrate how one [female] is at risk by circumcising and one [male] is safe by circumcising,” Riamit says.

Although they acknowledge the concerns arising from all stakeholders and recognize that access to any prevention method is a fundamental right, UNAIDS and WHO have proposed guidelines for decision-makers on human rights, ethical, and legal considerations dealing with male circumcision. Through this, they hope that national governments looking to provide this intervention will take steps to ensure that it is safe, voluntary, informed, and offered as part of comprehensive HIV prevention programming.

As Riamit affirms, “NGOs have [in the past] brought rites of passage defined in board rooms to communities…. The challenge [with male circumcision] is to empower the community to use this research knowledge, to themselves work out a rite of passage. Because culture must be dynamic and it can change, but it must come from them because the culture you are changing belongs to them.”

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How male circumcision works

There are various means through which circumcision is thought to reduce the transmission of HIV from women to men. In particular, the type, density, and distribution of HIV target cells in the penis have been sighted as contributing factors. For example, the underside of the foreskin has been found to have a high number of HIV target cells and therefore, a reduced or eliminated foreskin means less target cells for HIV. It has also been suggested that the foreskin is prone to tears and so its removal reduces the chance of cuts – or entry points for HIV. It is widely proven that circumcision decreases the likelihood of acquiring STIs and since lesions and ulcers act as entry points for HIV, a circumcised penis is less likely to be infected. A further suggestion is that the degree of keratinization – hardening – of the penile glans that is associated with male circumcision may provide protection.

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