Male circumcision (the cutting of the foreskin from the male penis) is increasingly gaining currency among medical researchers as an alternative method to reduce HIV-infection. But will this solution really work?
Researchers say that if all men in sub-Saharan Africa — the worst HIV/AIDS affected region in the world — were circumcised over the next decade, roughly two million new infections and 300 000 deaths could be averted.
An additional 3.7 million new HIV infections and 2.7 million deaths could be avoided in 20 years. Put simply, while the benefit of male circumcision to an individual man is immediate, a large scale impact of the intervention will be realized in two decades.
Aids risk lowered by 60%
In fact, evidence from observational studies in sub-Saharan Africa has shown that circumcised men have a lower risk of acquiring HIV infection than uncircumcised men. A study in South Africa showed that male circumcision might reduce by about 60 percent the risk of men contracting HIV through sexual intercourse with women.
The study focused on 3000 HIV-negative, uncircumcised men ages 18 to 24 living in a South African township. Of these, half were randomly selected for circumcision while the other half remained uncircumcised and served as a control group.
For every 10 uncircumcised men who contracted HIV, about three circumcised men contracted the virus. Researchers believed the findings were so significant they deemed it was unethical to proceed without offering the option to all males in the study.
The argument is that the inner surface of the penile foreskin contains Langerhans cells, which have HIV receptors, and is also vulnerable to disruptions during intercourse. Second, an intact foreskin exposes a man to a greater risk of ulcerative sexually transmitted infections, which in themselves are a risk factor for HIV acquisition. Furthermore, the virus’ chances of survival might be higher in a warm, wet environment like the one under the foreskin.
How will it affect society?
The evidence that circumcision may protect against HIV infection is now considered strong enough that further trials evaluating the efficacy of circumcision as part of an HIV prevention program have been advocated. This could herald a new era in HIV-prevention methods. But the question remains: what are the societal implications of such a solution?
Male circumcision has been practiced extensively in some sub-Saharan communities in rites of passage ceremonies from boyhood to manhood. The gruesome circumstances under which such practices occur may be exacerbated in the light of this new evidence. Other communities have not practiced it at all.
However, qualitative studies in the Botswana, Haiti, Tanzania, Zambia, and Zimbabwe revealed positive attitudes toward male circumcision in populations that do not traditionally practice it. From 45 to 85 percent of uncircumcised men in surveys expressed interest in the procedure if it is safe and affordable.
In spite of the interest in male circumcision, it is not a magic bullet in the fight against HIV-infection. To be effective, circumcision has to be promoted alongside condom use and faithfulness, long-established approaches in the fight against HIV/Aids.
Education and money will be essential
Some men may be tempted to engage in unprotected sex because they perceive they are protected by male circumcision. And some women may get a false sense of security when having sex with a circumcised man.
In itself, male circumcision provides little or no protection against urethral STDs such as gonorrhea and chlamydia and certainly cannot prevent unwanted pregnancies. This issue will need to be strongly emphasized in social campaigns.
To be successful, male circumcision will have to be complemented by a massive investment into education and counseling programs. There will be need for widespread and culturally sensitive dissemination of information that outlines the benefits and potential complications of male circumcision.
Another danger is that male circumcision can be risky or fatal if conducted by untrained personnel. There’s no doubt that with increased knowledge of male circumcision as a barrier against HIV, many men will try to perform it on their own. There will be obviously costs involved in getting circumcised which some people will try to circumvent.
Circumcising large numbers of adult men will be a major undertaking. If circumcision is not performed correctly it will increase the risk of infection. A major surgical system infrastructure needs to be developed. Who will fund this and how long will it take?
Also, most health facilities in sub-Saharan Africa are in a shambles and ill-equipped to perform widespread male circumcision. In addition, there’s also lack of social acceptability of circumcision in many of the sub-Saharan communities that have not traditionally practiced it.
Besides the safety and acceptability issues, perhaps the greatest drawback is the financial means required to undertake circumcision whole scale. Male circumcision will come with high costs through social mobilization efforts and upgrading of medical facilities. The more the men get circumcised, the more the success — and that’s tough ground.
Imagine the social message: If you’re a man, get cut today.