With millions of lives at stake over the next two decades, researchers and advocates at the AIDS 2008 Conference today called on the global health community to ramp up male circumcision to significantly reduce risk of HIV infection in Africa, and to move quickly to integrate the life-saving procedure into other comprehensive efforts to prevent transmission of the disease in the vulnerable nations of eastern and southern Africa.
At an event organized by Population Services International (PSI) in Mexico City today, speakers cited new findings suggesting that they can overcome many of the concerns donors and governments have given for not making circumcision more widely available to men in the region, among them fears that the procedure could not be done safely in low-resource settings, that it would lead to increased risk-taking behaviors, sexual dysfunction, and a backlash based on cultural and religious sensitivities.
New results from a male circumcision initiative implemented by PSI in Zambia suggest instead that cultural resistance can be overcome and that it is possible to carry out male circumcision (MC) safely and effectively in medically unsophisticated settings, using nurses and clinical officers to do the procedures as part of a comprehensive prevention program.
A recently published study in Kenya, described at the briefing by co-author Robert Bailey, an epidemiologist with the University of Illinois, Chicago, reported no increased risk-taking behaviors among newly-circumcised men. And a new study that Bailey's team presented for the first time at the conference in Mexico City concludes that compared to an uncircumcised control group, newly-circumcised men reported "increased penile sensitivity and enhanced ease of reaching orgasm," addressing fears that circumcision would reduce sexual pleasure and function.
"Based on the existing body of evidence, and our experience implementing male circumcision to strengthen our prevention efforts, we are asking the international community to help national governments and their partners to introduce male circumcision wherever HIV prevalence is greatest and circumcision rates are lowest—in the nations of eastern and southern Africa," said Dvora Joseph, Acting Director of the HIV Department at PSI, a nonprofit organization based in Washington, D.C. that addresses the health problems of low-income and vulnerable populations in more than 60 developing countries. Ms. Joseph was joined at the press briefing by Robert Bailey, who co-authored the post-circumcision studies of sexual function and risky behaviors in Kenya, and was an investigator on several of the studies that established the role of circumcision in protecting men from HIV.
Randomized control trials, including in Uganda, Kenya and South Africa, have shown that circumcision can reduce the transmission of HIV in heterosexual men by as much as 65 percent. Introducing it widely in sub-Saharan Africa, particularly in southern Africa where male circumcision rates are low, could prevent an estimated two million infections in the next ten years and save as many as four million lives over the next 20 years.
"As news gets out about the efficacy of male circumcision, we need to meet that demand with quality services and a comprehensive HIV prevention approach, and scale up male circumcision as an ethical, human rights issue," said PSI's Dvora Joseph, adding that the projects in Zambia and Kenya reported a significant unmet demand for circumcision among men, leading at times to a two-month waiting list in Zambia, where 500 men have been circumcised in the last 9 months.
She noted that despite subsequent recommendations by WHO and UNAIDS in favor of male circumcision as a prevention measure, many of the hardest-hit African nations are hesitating to introduce safe, accessible circumcision services to male citizens, and there has been little attempt to increase popular understanding of male circumcision and its impact on HIV.
"We seem to forget that we have an intervention that is 60 to 70 percent effective for preventing HIV in men, more effective than any vaccine currently under development," said Bailey. "But the word is getting out. Just by word of mouth, the demand is so great that already men are going to unqualified practitioners and experiencing serious complications. We must scale up our response rapidly to meet the demand for safe circumcision services."
Bailey was one of the first to discover that, for a number of reasons, circumcision protects against HIV infection. "Specific cells in the foreskin are favored targets for HIV infection," Bailey said. "Also, the inside of the foreskin lacks the tough covering that protects most skin from infection.
In a recent study published in the Public Library of Science, Bailey and his colleagues used a sophisticated statistical tool created to analyze their data and to conclude that there had been no increase in risky behaviors among 1,319 newly-circumcised men who had undergone intensive prevention counseling to help them understand that they were still vulnerable to HIV.
In Bailey's team's new study of sexual function and sexual satisfaction following male circumcision, to be presented at the AIDS conference on Tuesday, researchers reported that "Circumcision status was not associated with any sexual dysfunction or with specific sexual dysfunctions (premature ejaculation, pain during intercourse, erectile dysfunction) at follow-up visits." The study included a group of 2,784 participants between the ages of 18 and 24, and compared sexual function between circumcised and a control group of men who would be circumcised at a later time, assessing sexual satisfaction over a two-year period.
PSI's experiences in Zambia and those of Bailey's team in Kenya will guide circumcision efforts elsewhere in eastern and southern Africa, said Bailey, adding that any circumcision initiative must be integrated into existing HIV prevention programs in order to be effective. He noted, for example, that "a full package of HIV prevention measures" were responsible for the success of the Kenyan program in preventing risky behaviors after circumcision, as reported in the Public Library of Science. Interventions included HIV testing, STI diagnosis and treatment, the provision of condoms, and risk reduction counseling. Under such conditions, Bailey said, "the results of this study suggest that HIV risk behaviors are unlikely to increase. They may even decline as we saw in our study."
For PSI, known worldwide for its condom and communication programs in combating HIV, embracing male circumcision represents a significant new direction, Ms. Joseph said. Change grew out of the organization's acknowledgement that condoms and communications alone are insufficient and that circumcision—as part of a comprehensive HIV prevention program—can have an unprecedented impact on the burden of disease. "We were struck by this monumental research that shows circumcision having the greatest efficacy in curbing the spread of heterosexual transmission of HIV to date—greater than any vaccine in the pipeline today," she added.
In Kenya and Zambia, a wide range of health workers, hygienists, clinical officers and counselors are being trained so that male circumcision can be provided safely in the context of HIV prevention. Male circumcision can be done by "task shifting," or training relatively low-level healthcare workers, which prevents the programs from siphoning off workers from other projects.
PSI invested its own resources in Zambia to help meet demand for safe adult male circumcision, starting in 2007 with one free-standing facility. Since then, more than 500 men have been circumcised through the program, which is co-located with HIV counseling and testing services, treatment for sexually-transmitted diseases and risk reduction counseling. At the same time, PSI has also conducted quantitative and qualitative research to better understand key motivators and barriers to accessing circumcision services. The program reported the following findings, several of which address concerns that religious and cultural resistance would prevent the acceptance of circumcision programs:
- Outside of religious or cultural contexts, male circumcision is becoming increasingly accepted as HIV prevention and circumcision become more clearly linked.
- Attitudes and beliefs about MC and towards those who practice it are mixed, with, on one hand, the image of circumcised men as "free in both mind and body of concerns over HIV," and, on the other, the sense that seeking circumcision suggests the person is seeking decadent pleasures or trying to be rid of a sexually-transmitted disease.
- Male peers can influence their friends to circumcise, as almost 50 percent of the clients learned of the circumcision program from their friends or family members.
- Penile hygiene appears to be an important motivator for men seeking MC services, with both circumcised and uncircumcised men agreeing that male circumcision leads to better genital hygiene.
- Perceptions around sexual pleasure and sexual performance may play into decision-making, as circumcision is believed to result in better, longer-lasting sex because the penis becomes 'harder' and 'bigger.'
Speakers at the briefing said that donors and national governments should not be overly concerned about cultural resistance to male circumcision. Their experience in Zambia and Kenya suggests that cultural resistance can easily be overcome. "Most interesting to me," Bailey said, "was how many men seek out the service without our doing any marketing at all of the male circumcision program, leading to the concern that awareness of the impact on transmission, without access to services, may lead to unsafe practices."
PSI is a nonprofit organization based in Washington, D.C. that harnesses the vitality of the private sector to address the health problems of low-income and vulnerable populations in more than 60 developing countries. With programs in malaria, reproductive health, child survival and HIV, PSI promotes products, services and healthy behavior that enable low-income and vulnerable people to lead healthier lives. Products and services are sold at subsidized prices rather than given away in order to motivate commercial sector involvement. PSI is the leading nonprofit social marketing organization in the world.
- Williams et al. The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa. PLoS Medicine, Vol. 3, No. 7, e262 DOI: 10.1371/journal.pmed.0030262
- Krieger et al. Adult Male Circumcision Outcomes: Experience in a Developing Country Setting. Urologia Internationalis, 2007; 78 (3): 235 DOI: 10.1159/000099344
- Mattson et al. Risk Compensation Is Not Associated with Male Circumcision in Kisumu, Kenya: A Multi-Faceted Assessment of Men Enrolled in a Randomized Controlled Trial. PLoS ONE, 2008; 3 (6): e2443 DOI: 10.1371/journal.pone.0002443
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