The Right Kind of Cut?

A little piece of broadcasting history was made here in Lusaka about a year ago when the local BBC World Service reporter became the first man to undergo a circumcision live on air. The squeamish amongst you will be glad to hear that the audio recording is no longer available on the archive service but I am told that beyond a few sharp intakes of breath, Kennedy was able to commentate quite comfortably throughout the procedure.

Why, you might ask, is a BBC reporter putting himself through such an intimate operation live on the air? Male circumcision has become quite a hot topic in HIV prevention circles in the last few years after it was shown that men from regions where circumcision was traditionally performed had lower HIV rates than in those areas where it was not. Recent randomised trials have shown that circumcision can in fact reduce transmission rates amongst men by between 50 and 60%.

These are very impressive numbers in the world of novel HIV prevention strategies. Strategies beyond  A,B,C (Abstain or Be faithful or Condoms) have seen some pretty depressing results in the last few years. Vaccine trials have failed spectacularly and any hopes that remain are centered on topical microbiside gels which need to be applied by women daily and have shown some modest successes.

So why does circumcision seem to make such a big difference? Well without getting too heavily into the details, the cells under the foreskin are highly susceptible to being infected by the virus and thus by removing it, they become hardened and less likely to become infected.

Recently presented mathematical models based on a generalised HIV epidemic (prevalence  of 18% in men and 25% in women) – very close to the real Zambian figures – show that a scale up in circumcised males could reduce HIV prevalence by 8% in one year and by 25% in 10 years. These numbers only work if circumcision is taken up by the masses and 75% of men get the cut.

Of course the critical thing to note is that the risk for a circumcised man to contract HIV from unprotected sex is reduced but it is certainly not eliminated and therein lies the rub. The same model shows that if men relax their behaviour towards safer sex and condom use dropped by 40% in casual relationships and 20% with sex workers, it would wipe out all the benefits associated with mass circumcision.

So now the public health community have an interesting new strategy to consider in the fight against HIV and a whole range of new issues to deal with. How do you encourage large numbers of men to come forward for surgery? How do you find enough skilled health professionals to carry out all these surgeries? And most importantly of all, how do you ensure that circumcised men do not start to engage in unprotected sex, perhaps even more than before?

My housemate is a nurse on the urological ward of the same University Teaching Hospital where the BBC recording was made, and these days their beds are full of men coming forward for the procedure. However when I asked her how many she thought take  the counseling about the continued need for condom use seriously, she felt that it was probably less than half.

So there you have it, the perfect public health dilemma. Something that has the potential to reduce risk at the level of the whole population but may actually increase the risk that any one individual exposes themselves to.

Nothing, it seems, is straightforward or simple about fighting this epidemic.

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2 Responses to “The Right Kind of Cut?”
  1. Mark Lyndon says:

    There are seven African countries where men are more likely to be HIV+ if they’ve been circumcised: Rwanda, Cameroon, Ghana, Lesotho, Malawi, Swaziland, and Tanzania. For example in Rwanda, 3.5% of circumcised men have HIV, but only 2.1% of intact men. In Cameroon, 4.1% of circumcised men have HIV, but only 1.1% of intact men. If circumcision really worked against AIDS, this just wouldn’t happen. We now have people calling circumcision a “vaccine” or “invisible condom”, and viewing circumcision as an alternative to condoms.

    ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.

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  1. […] Low rates of male circumcision – As we have discussed previously on the blog, this is a relatively recent addition to the HIV prevention arsenal and with only a few tribes […]



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